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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/immigranthealthcOOdavi 


BY  EDUCA^lOnr 


WHAT  WAT  OF  TEACHING  IMMIGRANTS  HABITS  OF  HEALTH 
IS  MOEE  EFFECTIVE  IN  AMERICA? 


AMERICANIZATION  STUDIES 
ALLEN  T.  BURNS,  DIRECTOR 

IMMIGRANT  HEALTH 

AND  THE 

COMMUNITY 


BY 
MICHAEL  M.  DAVIS,  Jr. 

DIEECTOB,    BOSTON    DISPENSARY 


HARPER  &  BROTHERS  PUBLISHERS 

NEW    YORK    AND     LONDON 
1921 


4a  7 


Immigrant  Health  and  the  Community 


Copyright,  1921,  by  Harper  &  Brothers 
Printed  in  the  United  States  of  America 


PUBLISHER'S  NOTE 

The  material  in  this  volume  was  gathered  by  the 
fe  Division  of  Health  Standards  and  Care  of  Stud- 

ies in  Methods  of  Americanization. 

Americanization  in  this  study  has  been  con- 
sidered as  the  union  of  native  and  foreign  born 
in  all  the  most  fundamental  relationships  and 
activities  of  our  national  life.  For  Americaniza- 
tion is  the  uniting  of  new  with  native-born 
Americans  in  fuller  common  understanding  and 
appreciation  to  secure  by  means  of  self-govern- 
ment the  highest  welfare  of  all.  Such  American- 
ization should  perpetuate  no  unchangeable  po- 
litical, domestic,  and  economic  regime  delivered 
once  for  all  to  the  fathers,  but  a  growing  and 
broadening  national  life,  inclusive  of  the  best 
wherever  found.  With  all  our  rich  heritages, 
Americanism  will  develop  best  through  a  mutual 
giving  and  taking  of  contributions  from  both 
newer  and  older  Americans  in  the  interest  of  the 
commonweal.  This  study  has  followed  such  an 
understanding  of  Americanization. 


FOREWORD 

This  volume  is  the  result  of  studies  in  methods 
of  Americanization  prepared  through  funds  fur- 
nished by  the  Carnegie  Corporation  of  New  York. 
It  arose  out  of  the  fact  that  constant  applications 
were  being  made  to  the  Corporation  for  contribu- 
tions to  the  work  of  numerous  agencies  engaged 
in  various  forms  of  social  activity  intended  to 
extend  among  the  people  of  the  United  States 
the  knowledge  of  their  government  and  their 
obligations  to  it.  The  trustees  felt  that  a  study 
which  should  set  forth,  not  theories  of  social 
betterment,  but  a  description  of  the  methods  of 
the  various  agencies  engaged  in  such  work,  would 
be  of  distinct  value  to  the  cause  itself  and  to  the 
public. 

The  outcome  of  the  study  is  contained  in  eleven 
volumes  on  the  following  subjects:  Schooling  of 
the  Immigrant;  The  Press;  Adjustment  of 
Homes  and  Family  Life;  Legal  Protection  and 
Correction;  Health  Standards  and  Care;  Natu- 
ralization and  Political  Life;  Industrial  and  Eco- 
nomic Amalgamation;  Treatment  of  Immigrant 
Heritages;  Neighborhood  Agencies  and  Organi- 
zation; Rural  Developments;  and  Summary. 
The  ei^ire  study  has  been  carried  out  under  the 

ix 


FOREWORD 

general  direction  of  Mr.  Allen  T.  Burns.  Each 
volume  appears  in  the  name  of  the  author  who 
had  immediate  charge  of  the  particular  field  it 
is  intended  to  cover. 

Upon  the  invitation  of  the  Carnegie  Corpora- 
tion a  committee  consisting  of  the  late  Theodore 
Roosevelt,  Prof.  John  Graham  Brooks,  Dr.  John 
M.  Glenn,  and  Mr.  John  A.  Voll  has  acted  in 
an  advisory  capacity  to  the  director.  An  edi- 
torial committee  consisting  of  Dr.  Talcott  Will- 
iams, Dr.  Raymond  B.  Fosdick,  and  Dr.  Edwin 
F.  Gay  has  read  and  criticized  the  manuscripts. 
To  both  of  these  committees  the  trustees  of  the 
Carnegie  Corporation  are  much  indebted. 

The  purpose  of  the  report  is  to  give  as  clear 
a  notion  as  possible  of  the  methods  of  the  agen- 
cies actually  at  work  in  this  field  and  not  to 
propose  theories  for  dealing  with  the  complicated 
questions  involved. 


TABLE  OF  CONTENTS 

PAGB 

Publisher's  Note  vii 

Foreword  *^ 

Table  of  Contents  xi 

List  of  Diagrams  xvii 

Map  xvii 

Chart  xvii 

List  of  Tables  xix 

List  of  Illustrations  xxiii 

Litroduction  xxv 

PAET  I 

CHAPTEB  _  _^^ 

AMERICANIZATION  AND  HEALTH 

I.  Theories  versus  People  3 

Psychological  Factors  m  Health  Work  4 

The  Big-stick  Theory  10 

The  Laissez-faire  Theory  15 

The  Democratic  Theory  18 

PART  n 
IMMIGRANT  CONDITIONS  AND  POINTS  OF  VIEW 

n.  Sickness  Among  the  Foreign  Born  27 

The  Burden  of  Sickness  9&^^ 

General  Morbidity  Statistics  31 

Morbidity  of  Special  Races  34 

High  Morbidity  of  Italians  36 

Insanity  Among  the  Foreign  Born  39 

Racial  Differences  Apparent  40 
xi 


CONTENTS 

CHAPTER  PAOa 

III.  Death  Rates  of  the  Foreign  Born  42 

Racial  Differences  in  Death  Rates  43 

Deaths  from  Degenerative  Diseases  48 

Pneumonia  and  the  Acute  Infections  50 

Tuberculosis  53 

High  Mortality  of  the  Irish  66 

Low  Mortality  of  Russians  57 

-  Italian  Death  Rate  Not  Uniform  58 

V  Infant  Mortality  58 

^Need  for  Uniform  Records  63 

IV.  Housing  Versus  Health  70 

Homes  Available  to  the  Immigrant  76 

Prevalent  Tenement  Conditions  78 
Boarders  in  Every  Third  Foreign-born  Home    80 

American  Housing  vs.  Immigrant  Health?  82 

Testimony  of  Health  Officers  84 

Better  Housing  89 

V.  Self-Help  and  Health  92 

Racial  Basis  for  Benefit  Societies  93 

Four  Types  of  Benefit  Societies  94 

General  Character  of  Societies  95 

Church  Keystone  of  Polish  Societies  97 

Italians  from  Same  Village  Unite  99 

Nationalistic  Interests  of  Jews  101 

Hospital  Care  Among  the  Greeks  101 

Firm  Financial  Basis  of  the  Portuguese  102 

Benefit  Societies  in  Chicago  103 

Benefit  Societies  Transitory  106 

Inadequate  as  Health  Agencies  107 

Advantage  in  Friendly  Assistance  110 

VI.  Immigrant  Backgrounds  112 

Peasant  Origins  113 

,^-^Public  vs.  Private  Health  Administration     117 

^Unfamiliarity  with  Medical  Resources  120 

^  New  Relations  to  Government  in  this  Country  121 

xii 


CONTENTS 

3APTER  PAGE 

Changed  Relation  between  Social  Classes  122 
Transition  from  Agriculture  to  Industry  124 
Physiological  Strain  Due  to  Change  in  En- 
vironment 124' 
Unfamiliarity  of  Language  126' 

VII.  Immigrant  Resources  for  Medical  Care  129 

Home  and  Neighborhood  130 

The  Drug  Store                                    ^  131 

Private  Physicians  133 

Inadequate  Supply  of  Immigrant  Doctors  135 

DiflBculties  of  Immigrant  Practice  138 

PART  in 

SPECIAL  IMMIGRANT  PROBLEMS 

Vin.  The  IVIedical  Quack  145 

Unscrupulous  Methods  147 

Exposure  through  Publicity  163 
Responsibility  of  the  Foreign-language  Press  164 

Federal  Legislation  170 

State  Legislation  174 

Law  Enforcement  177 

IX.  Birth  Rates  and  Maternity  Customs  184 

Fecundity  and  Maternity  Death  Rates  184 

Inadequate  Maternity  Care  187 

Backgrounds  for  Motherhood  190 

X.  The  Midwife  196 

Reasons  for  Using  the  Midwife  199 

Status  of  the  American  Midwife  203 

Quality  of  American  Midwifery  210 

XI.  Adequate  Maternity  Care  218 

The  Prenatal  Clinic  221 

Maternity  Center  Association  of  New  York  223 
xiii 


CONTENTS 

CHAPTBR  PAOB 

Maternity  Service  by  Medical  Schools  225 

A  Practical  Plan  232 

The  Cost  of  a  Community  Plan  233 

Districting  the  Service  238 

Visiting  Housekeepers  Essential  240 

Interpreting  241 

Advantages  of  the  Plan  241 

The  Co-operation  of  the  Layman  243 

Xn.  Immigrant  Diets  and  American  Food  246 

Replacing  Italian  Food  253 

Jewish  Religious  Restrictions  257 

People  of  the  Near  East  264 

Poles  and  Other  Slavic  Peoples  270 

^^Application  to  Health  Work  274 

^Knowledge  of  Immigrant's  Food  Essential      275 

^  Need  for  Printed  Material  275 

^  International  Menus  for  Institutions  277 

Food  Clinics  Indispensable  278 


PART  IV 
AMERICAN  AGENCIES  AND  METHODS 

XIII.  Field  Work  with  the  Immigrant  283 

The  Problem  of  Approach  284 

Barrier  of  Language  286 

Knowledge  of  Backgrounds  294 

Localization  of  Health  Work  299 

Summary  302 

XIV.  The  Hospital  805 
y"  Immigrant  Attitudes  306 

"^y^veX^  for  the  Foreign  Born  311 

y^ses  of  Interpreters  313 

^-'^Social-Service  Department  318 

^  Jmmigrant  Hospitals  321 

'^^^/Need  for  a  Community  Plan 


323 


XIV 


CONTENTS 

CTU.PTER  PAQB 

XV.  The  Dispensary  326 

Use  by  Immigrants  830 

Meeting  the  Needs  of  Individuals  334 

Mediums  of  Communication  336 

Importance  of  the  Admission  Desk  336 

Social  Service  Department  338 

Value  of  Food  Clinic  339 

Foreign-born  Personnel  339 

Need  for  Localization  340 

Community  Plan  for  Medical  Service  342 

Co-operation  of  Immigrants  343 

XVI.  Industrial  Health  Work  344 

Medical  Service  in  Industrial  Establishments  349 

Accident  Prevention  352 

Benefits  and  Co-operative  Plans  357 

Extension  of  Service  to  Homes  360 

Housing  362 

Floating  Labor  Camps  365 

The  Pioneer  Mining  Community  368 

Summary  371 

XVn.  Public  Health  Work  376 

Experiments  in  New  York  380 

Health  Centers  in  Clevelfind  384 

Co-ordination  in  Buffalo  385 

A  Dispensary  in  Boston  386 

The  Social  Unit  Plan  387 

PART  V 
A  PROGRAM  FOR  HEALTH 

XVni.  Community  Organization  393 

The  Economic  Limitation  394 

'  The  Psychological  Limitation  396 

The  Professional  Limitation  398 

The  Social  Limitation  399 

XV 


CONTENTS 

CHAPTER  PAGE 

.^:p^  Health  Insurance  401 

Community  Organization  of  Medical  Service  404 
The  Localization  of  Health  Work  405 

Generalization  in  Field  Work  406 

Service  Organization  408 

Distribution  of  the  Financial  Burden  410 

Participation  by  the  Community  413    / 

Preventive  Medicine  Fostered  through  Cura- 
tive 417 
A  Small  Community  Program  419  ■■  "^ 

XIX.  National  Applications  429 

Tasks  for  National  and  Local  Organizations  429 
Need  for  a  Central  Standardizing  Agency       432      . 
Training  Health  Workers  432  y 

A    Clearing    House    for    Information    and 


Methods 

433 

Stimulation  of  Local  Organization 

435 

Health  Work  and  National  Stamina 

437 

No  Inherent  Racial  Superiority 

438 

Relative  Birth  Rate  Unimportant 

439 

Modern  Fitness  Defined 

443 

Natural  Selection  Promoted 

444 

The  Democratic  Process 

446 

Appendix 

449 

Recipes  of  the  Foreign  Born 

449 

The  Italians 

449 

The  Jews 

451 

Armenians,  Syrians,  Turks,  and  Greeks 

459 

Poles  and  Other  Slavs 

464 

Index  465 


LIST  OF  DIAGRAMS 

DIAGBAM  PAGE 

1.  Comparison  for  Each  Mother  Tongue  of  For- 

eign Born  in  the  United  States  in  1910 
and  the  Net  Increase  to  July,  1919  6 

2.  Proportion  of  Pneumonia  and  Other  Respira- 

tory Cases  to  All  Cases  Attended  by 
Henry  Street  Settlement  Nurses  36 

3.  Variation  by  Nationality  in  Death  Rates  per 

1,000,  of  All  Males  Five  Years  of  Age  and 
Over  in  New  York  City,  1917  46 

MAP 

Peoples  of  Europe — Their  Approximate  Locations  65 

CHART 

A  Suggested  Classification  of  the  Foreign-born  Popu- 
lation by  Mother  Tongue  66 


LIST  OF  TABLES 


TABLE 


I.  Relative  duration  of  illness  among  native 
and  foreign-born  white  persons  studied  by 
the  Illinois  Health  Insurance  Commission      30 

II.  Physical  rejections  in  alien  and  native  com- 
munities compared  32 

Hr.  Report  of  physical  examinations  on  drafted 
men  in  Local  Board  129,  New  York  City, 
1919  33 

IV.  Cases  of  pneumonia  and  other  respiratory 
diseases  attended  by  nurses  from  Henry 
Street  Settlement  35 

V.  Per  cent  of  fourteen  hundred  New  York 

school  children  showing  low  nutrition,  1907      37 

VI.  Per  cent  of  children  under  weight  in  East 
Orange,  New  Jersey,  by  nationality  of 
mother  38 

Vn.  Comparison  of  race  distribution  in  principal 

psychoses,  1918  39 

VTTT.    Age  distribution  of  the  population  of  the 

United  States,  1910  42 

IX.  Death  rates  per  1,000  population,  by  nativ- 
ity, for  registration  area,  1890  and  1900      43 

X.  Death  rate  for  white  persons  having  moth- 
ers born  in  specified  countries,  1900  44 

XI.  Death  rate  per  1,000  population  of  all  per- 
sons five  years  and  over,  by  nationality 
and  sex,  in  New  York  City  45 

xix 


LIST  OF  TABLES 

TABLE  PAGE 

XII.  Death  rates  per  1,000  in  principal  nativity 
classes  of  New  York  State  population, 
1910  47 

Xm.  Death  rate  from  certain  diseases  among 
whites,  classijfied  according  to  birthplace 
of  mother,  1900  48 

XrV.  Death  rate  of  whites  from  certain  respira- 
tory diseases  and  acute  infections,  clas- 
sified by  birthplaces  of  mothers,  per  100,- 
000  population,  1900  51 

XV.  Death  rate  of  whites  from  consumption,  per 

100,000  population,  1900  54 

XVI.  Mortality  of  children  under  five  years  of  age 
and  under  one  year,  in  New  York  City  in 
1915,  classified  by  birthplace  of  mother        61 

XVII.  Mortality  rates  of  infants  under  one  year 
classified  by  nationality  of  mothers,  in 
three  cities  62 

XVin.  Per  cent  of  households  keeping  boarders  or 
lodgers,  by  general  nativity  and  race  of 
head  of  household  81 

XIX.  Independent   foreign    benefit    societies   in 

Chicago  105 

XX.  Periods  in  which  155  foreign  benefit  socie- 
ties were  founded  106 

XXI.  Number  and  characterization  of  quack  ad- 
vertisements translated  from  foreign- 
language  newspapers  150 

XXII.  Percentage  of  advertising  income  derived 
from  medical  advertising  in  certain  for- 
eign-language newspapers  165 

XX 


LIST  OF  TABLES 

Table  page 

XXIII.  Infant   mortality   in   European   countries, 

1908  185 

XXIV.  Death  rates  from  affections  connected  with 

pregnancy,  1900  186 

XXV.   Days  in  bed  after  delivery  of  cases  cared  for 

by  midwives.  New  York  City,  1912-19     189 

XXVI.  Births  attended  by  midwives  in  New  York 
State,  according  to  the  nativity  of  the 
mothers,  1916  197 

XXVII.  Fee  rates  for  delivery  of  285  cases.  New 

York  City,  1912-19  202 

XXVIII.  Death  rates  per  1,000  births  for  infants  at- 
tended at  birth  by  midwives,  physicians, 
and  hospitals,  1915-16-17  214 

XXIX.  The  kinds  of  maternity  care  secm-ed  by  pa- 
tients of  various  races  in  New  York, 
1903-18  231 

XXX.  Number  and  per  cent  of  1,055  cases  treated 
by  the  Central  Free  Dispensary,  Rush 
Medical  College,  by  nationality  331 

XXXI.  Number  and  per  cent  of  3,536  New  York 
City  cases  using  hospitals  and  dispen- 
saries, by  nationality  333 

XXXn.  Outstanding  problems  of  the  foreign  born  m 
industry,  mentioned  by  seventy  indus- 
trial physicians  348 

XXXm.  Comparison  of  the  weight  and  height  of 
children  of  different  ages  living  in  Bourne- 
ville  and  Birmingham,  England  362 


LIST  OF  ILLUSTRATIONS 

PAGE 

What  Way  of  Teaching  Immigrants  Habits  of  Health 

is  More  Effective  in  America?  Frontispiece 

Immigrants  First  Go  to  Live  in  Crowded  Districts  and 

Old  Houses  73 

In  Peasant  Countries  Bathing  and  Washing  were  Done 

Out  of  Doors  86 

Is  It  Any  Wonder  It  Takes  Time  to  Learn  to  Use  a 

Bathtub?  87 

In  Europe  Garbage  and  Waste  were  Burned  or  Fed  to 

the  Animals  118 

In  America  Disposal  of  Refuse  is  a  Public  Function      119 

The  Immigrants  Lived,  Worked,  and  Played  Out  of 

Doors  in  Europe  125 

Development  Needed  in  Maternity  Care  227 

Nurse  Must  Relieve  the  Doctor  in  Caring  for  Many 

Babies  Born  237 

In  Europe  the  Milk  Supply  was  in  the  Front  Yard        250 

In  America  Milk  from  a  Distance  Makes  New  Re- 
quirements 251 

Temporary  Shanties  May  Be  the  Only  Homes  for  Im- 
migrants in  Mining  Communities  369 

Community  Equipment  for  Health  Education  411 

xxiii 


INTRODUCTION 

The  purpose  of  this  book  is  to  help  interrelate  the  so- 
called  Americanization  movement  in  the  United  States 
with  the  many  efforts  toward  the  betterment  of  health 
conditions  and  the  improvement  of  facilities  for  the 
care  and  prevention  of  disease.  Americanization 
should  include  interplay  between  native  and  foreign 
born  in  all  the  important  aspects  of  life,  including  the 
care  and  promotion  of  health.  Therefore,  the  physi- 
cians, nurses,  social  workers,  and  administrators  who 
are  professionally  concerned  with  medical  and  health 
work  need  to  study  people  as  well  as  technique,  and 
adapt  the  policies  and  methods  of  their  work  to  psy- 
chological as  well  as  technical  conditions. 

The  larger  part  of  the  book  has  been  written  by 
the  undersigned,  as  chief  of  that  division  of  the 
Americanization  Study  entitled  Health  Standards 
and  Care.  The  writer  accepts  general  responsibility 
for  the  book  as  a  whole,  due  credit  being  given  in  this 
preface  to  the  members  of  the  staff  or  to  co-operating 
specialists  for  the  responsible  parts  which  they  have 
taken  in  collecting  and  summarizing  material  for 
particular  parts  of  the  book. 

Miss  Linda  James  was  general  assistant  to  the  chief 
of  this  division  of  this  study  during  the  year  and  a 
half  of  its  course.  She  is  especially  responsible  for 
gathering  the  material  on  industrial  medicine  in  re- 
lation to  the  foreign  born,  and  for  the  statistical 

XXV 


INTRODUCTION 

material  in  Chapters  II  and  III.  Dr.  Walter  H. 
Brown,  Health  Officer  for  Bridgeport,  Connecticut, 
was  responsible  for  the  general  survey  of  health  de- 
partments; Miss  Bertha  M.  Wood,  head  of  the  food 
clinic  of  the  Boston  Dispensary,  for  the  valuable  study 
of  the  dietary  problems  of  a  number  of  races;  Miss 
Elizabeth  C.  Watson  of  New  York  for  the  midwife 
material,  and  Mr.  Samuel  M.  Auerbach  and  Mrs. 
Janet  Hayes  Davis  for  the  facts  about  the  medical 
quacks. 

The  co-operation  of  several  associations  dealing 
with  particular  sections  of  our  field  proved  of  the 
greatest  assistance.  The  National  Organization  for 
Public  Health  Nursing  generously  permitted  one  of 
its  executive  secretaries,  Mrs.  Bessie  Ammerman 
Haasis,  to  devote  a  portion  of  her  time  as  a  member 
of  the  staff  of  this  division  to  a  survey  of  the  policies 
and  methods  of  visiting  nursing  organizations  in  re- 
lation to  the  foreign  born.  The  American  Association 
of  Hospital  Social  Workers  similarly  allowed  its 
executive  secretary.  Miss  M.  Antoinette  Cannon,  to 
give  a  portion  of  her  time  to  a  survey  of  the  working 
methods  of  social-service  departments  with  immigrant 
patients. 

The  helpful  co-operation  of  the  United  States  Pub- 
lic Health  Service  and  the  Bureau  of  Labor  Statistics 
is  cordially  acknowledged.  Dr.  Harry  E.  Mock,  presi- 
dent of  the  AmericanAssociation  of  Industrial  Physi- 
cians and  Surgeons,  generously  gave  much  time  in  an 
advisory  way  to  that  part  of  the  study  concerned  with 
industrial  medicine.  The  number  of  individuals  and 
of  organizations  who  have  assisted,  by  permitting  us 
to  analyze  data  which  they  had  collected  or  by  fur- 

xxvi 


INTRODUCTION 

nishing  us  original  or  published  material  of  their  own, 
has  been  too  considerable  to  mention  here,  but  an 
effort  has  been  made  to  give  credit  and  express  ap- 
preciation in  the  text. 

The  compilation  of  material  for  this  book  was  com- 
pleted December,  1919,  and  this  date  should  be  borne 
in  mind  in  considering  the  statistics  and  the  discussion 
in  general. 

We  are  under  deep  indebtedness  to  the  Harvard 
Medical  School  for  generously  furnishing  comfortable 
office  rooms  for  the  staff  of  this  division  without 
charge  for  rent.  The  nature  of  this  study  has  required 
visits  to  many  parts  of  the  country  on  the  part  of 
certain  members  of  the  staff,  and  hundreds  of  inter- 
views with  physicians  in  private  practice,  public-health 
officers,  hospital  superintendents,  nurses,  dietitians, 
social  workers,  officials  and  leaders  in  immigrant  or- 
ganizations, the  priests  and  ministers  of  the  churches, 
and,  above  all,  with  many  immigrants  themselves, 
medical  or  lay  workers  among  their  own  race,  or 
simply  mothers  or  fathers  or  people  who  gave  us 
something  of  themselves,  their  characteristics,  their 
views,  and  their  needs.  The  belief  that  America  ought 
to  see  to  it  that  its  newcomers  have  facilities  for  better 
medical  care  and  for  more  and  better  public-health 
work  has  been  given  a  foundation  which  cannot  be 
transferred  to  the  reader  by  pages  of  statistics  or  of 
argument. 

Much  is  said  just  now  in  criticism  of  the  alien,  par- 
ticularly of  the  temporary  residents  in  this  country. 
But  most  of  the  immigrant  men  and  women  whom  we 
have  seen  are  raising  their  families  here,  and,  though 

not  losing  their  affection  for  the  land  of  their  birth, 

xxvii 


INTRODUCTION 

have  burned  their  bridges  against  return.  Interviews 
with  them  have  left  us  with  a  sense  of  gratitude  for 
the  patience,  the  sympathy,  the  real  understanding 
with  which  they  have  endured  and  responded  to  our 
questioning,  and  for  the  larger  knowledge  of  human 
nature  and  human  needs  which  they  have  given  to 
us  in  much  fuller  measure  than  anything  we  have 
been  able  to  return  to  them.  The  professional  desire 
for  better  medical  and  health  service  to  these  foreign- 
born  fellow  citizens  has  thus  been  warmed  and  up- 
lifted by  the  wish  that  they  and  their  children  shall 
share  more  fully  than  heretofore  in  the  heritage  of 
health  and  happiness  of  the  New  World. 

Michael  M.  Davis,  Jr. 

Cambridge,  Massachusetts, 
July,  1920. 


IMMIGRANT    HEALTH 
AND  THE  COMMUNITY 

Part  I 
AMERICANIZATION  AND  HEALTH 


IMMIGRANT   HEALTH 
AND  THE  COMMUNITY 


THEORIES  VERSUS  PEOPLE 

"The  healthy  know  not  of  their  health,  but  only  the 
sick."  With  the  advance  of  medical  science  this 
saying  of  the  nineteenth  century  should  be  changed 
by  the  twentieth  century  to,  "The  healthy  learn  to 
promote  their  health;  the  sick  wish  they  had."  If  a 
town  is  stricken  with  typhoid  fever  it  must  no  longer 
blame  Providence,  but  itself.  Health  can  no  longer 
be  regarded  as  a  negative  or  passive  state,  the  mere 
absence  of  disease.  Health  is  a  positive  quantity, 
an  ideal  of  individual  or  community  life,  capable  of 
being  reaUzed  by  methods  which  are  more  or  less 
known. 

This  spread  of  knowledge  has  led  in  recent  years 
to  aggressive,  organized  movements  for  the  care  of 
illness  and  the  promotion  of  health.  The  medical 
investigator,  the  executive  officer  of  the  health  de- 
partment, the  hospital,  the  dispensary,  the  public- 
health  nurse,  the  social  worker,  are  all  concerned  with 
the  study  of  medical  methods  and  the  application  to 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  care  and  prevention  of  disease.  Much  of  this 
study  has  to  do  with  technique,  such  as  periods  and 
modes  of  quarantine,  organization  of  hospitals,  clinics, 
or  sanatoriums,  methods  of  prenatal  care  or  of  baby- 
feeding.  A  large  part  of  medical  and  health  work  de- 
pends for  its  effectiveness  upon  the  careful,  continuous 
study  of  just  such  impersonal  matters  of  technique. 
Without  underestimating  the  value  and  necessity 
of  technique,  it  must,  nevertheless,  be  pointed  out 
that  effective  medical  and  health  work  must  take  into 
account  yet  another  element.  The  aim  of  medical  and 
health  work  is  to  secure  practical  results  in  curing 
disease,  reducing  morbidity  and  mortality,  promoting 
wholesome  and  efficient  living.  Work  for  these  aims 
involves  two  fields  of  human  knowledge.  One  is 
physiology,  taken  in  the  broad  sense  of  that  word. 
Medicine  and  its  related  sciences,  such  as  bacteriology 
and  chemistry,  aim  to  ascertain  the  reactions  of  the 
human  organism  to  various  conditions  of  activity, 
climate,  infection,  and  so  forth.  This  constitutes 
what  may  be  called  the  physiological  field. 

PSYCHOLOGICAL  FACTORS  IN  HEALTH  WORK 

The  other  field  is  psychological  or  social.  Medical 
and  health  work  involves  the  application  of  science, 
or  a  group  of  sciences,  to  groups  of  human  beings  in 
both  their  individual  and  collective  relationships. 
It  deals  with  people  and  is  administered  by  people. 
What  the  executives  and  field  workers,  what  their 
patients  and  their  public,  think  and  feel  about  such 
work  is  fundamental  in  determining  its  extent  and 
effectiveness  at  any  given  period. 


THEORIES  VERSUS  PEOPLE 

The  study  of  people  is  as  important  a  factor  in  its 
success  as  are  the  noiihuman  elements  of  technique. 
The  health  officer,  the  hospital  superintendent,  the 
public-health  nurse,  and  the  social  worker,  all  being 
members  of  the  human  family,  consider  this  human 
element  in  a  more  or  less  conscious  way  during  their 
daily  work.  The  extent  to  which  they  do  this  is  a 
measure  of  what  we  commonly  call  their  wisdom  and 
tact.  But  beyond  these  individual  considerations  of 
personality,  the  sciences  of  psychology,  economics, 
and  sociology  have  a  definite  application  to  medical 
and  health  work.  Inexact  as  these  sciences  are  called, 
they  yet  bear  lessons  of  importance  for  the  physician 
or  health  worker.  Conscious  and  deliberate  research 
in  this  direction  is  urgently  needed  and  will  repay 
serious  attention. 

There  are  thirteen  million  foreign-born  persons  in 
the  United  States,  and  about  twenty  million  more  of 
foreign-born  or  mixed  parentage.  These  people,  be- 
cause of  their  racial  inheritance  and  their  position  as 
immigrants,  have  developed  a  psychology  and  live 
under  social  and  economic  conditions  very  different 
from  those  of  the  native  born.  For  these  reasons  the 
problem  of  the  human  factor  is  intensified  in  medical 
and  health  work  with  the  foreign  element  in  our 
population.  Also,  they  suffer  more  than  the  native 
bom  from  failure  to  consider  this  factor,  for  American 
medical  and  health  methods  grew  out  of  native  con- 
ditions and  so  fit  them  at  least  approximately.  The 
study  of  health  problems  among  the  foreign  born 
here  in  the  United  States  is,  therefore,  a  necessary  part 
of  the  investigation  of  Americanization  methods,  as 
well  as  a  method  of  approaching  the  study  of  the 

2  5 


IMMIGRANT  HEALTH  AND  COMMUNITY 

DIAGRAM  I. — COMPARISON  FOR  EACH  MOTHER  TONGUE  OF 
FOREIGN  BORN  IN  THE  UNITED  STATES  IN  1910  AND 
THE  NET  INCREASE  TO  JULY,  1919,  ACCORDING  TO  THE 
U.  S.  BUREAU   OF   IMMIGRATION  REPORTS 


THOUSANDS 
SCO   ^000   1500   2000   2500   3000   3500 


ENGUSH,  SCOTCH 
AND  IRISH 

GERMAN 

ITALIAN 

SCANDINAVIAN 

HEBREW  &  YIDDISH 

POUSH 

FRENCH 

SPANISH  AND 
MEXICAN 

MAGYAR 

BOHEMIAN  AND 
MORAVIAN 

SLOVAK 

DUTCH  AND 
FLEMISH 

UTHUANIAN 

BULGARIAN.SERBIAN 
AND  CRdATIAN 

FINNISH 

GREEK 

PORTUGUESE 

JAPANESE 

RUSSIAN 

CHINESE 
ROUMANIAN 

SYRIAN 
RUTHENIAN 
ARMENIAN 

TURKISH 

.... 

■   •    ■  • 

1  ' 

i 

^™ 

1 

1 

1^ 

1 

■  1 

^HM 

1 

H 

P 
? 
f 
i> 
P 
i 

DecreoBo 
Detmam 

C 

OMPARISON  OF  THE  NET  INCREASE 

SINCE  1910  OF  THE  IMMIGRANTS 

OF  THE  OLD  AND  NEW  RACES 

OLO^^ 

8.075.641       -        (HI 

1 1,009,674 

Mrw    |__5rl^0-536      « 

^    Hii2.016.523 

- 

TOTAL] 
NETADI 

1910 

)moNs 

1911*19 

human  element  in  health  technique  within  a  field 
sufficiently  definite  and  limited  to  be  practicable. 
Obviously  the  Italian,  the  Jew,  the  Scandinavian, 

6 


THEORIES  VERSUS  PEOPLE 

the  Pole,  and  the  Syrian  are  not  all  alike.  They  dif- 
fer in  various  physical  characteristics,  in  language 
and  traditions.  They  are  human  varieties,  we  may 
say.  But  is  not  health  a  problem  of  the  human 
species.'^  Have  these  human  varieties,  along  with 
their  admitted  differences,  any  characteristically  dif- 
ferent problems  of  health  or  disease?  In  health  mat- 
ters, do  they  as  a  group  differ  from  that  other  human 
variety  known  as  native-born  Americans? 

These  questions  are  partly  answered  by  com- 
parative statistical  studies  of  sickness  or  mortality 
among  different  peoples  here  and  abroad.  In  large 
part,  however,  they  are  answered  by  other  kinds  of 
data.  Psychological  and  social  differences  between 
"races"  or  national  groups,  as  contrasted  with  one 
another  and  with  the  native-born  American,  may  be 
found  to  create  the  need  for  different  methods  of 
medical  or  health  work. 

This  is  the  general  problem.  We  deal  with  the 
specific  situation  in  America.  We  seek  to  discover 
how  far  the  foreign  born  present  distinctive  problems 
of  health  and  disease  and  how  our  methods  of  medical 
and  health  work  need  to  be  adapted  to  the  foreign 
bom  in  order  to  secure  the  best  results. 

The  characteristic  qualities  of  different  groups  of 
our  foreign  born,  and  their  condition  in  the  United 
States,  must  be  briefly  reviewed,  so  that  we  may  have 
a  background  of  customs  and  traditions  to  which  to 
relate  matters  of  health  and  disease.  The  conditions 
and  problems  which  are  faced  by  those  interested  in 
medical  and  health  work  must  be  illustrated  by  field 
studies.  Health  departments,  antituberculosis  asso- 
ciations, industrial  or  commercial  establishments  doing 

7 


IMMIGRANT  HEALTH  AND  COMMUNITY 

medical  or  health  work  among  their  employees,  must 
be  considered  from  a  technical  point  of  view,  to  see 
how  their  methods  have  been  adapted  to  the  foreign 
bom,  or  have  failed  to  be  so  adapted.  Examples  of 
effective  methods  which  might  be  of  practical  service 
if  generally  known,  should  be  presented  in  some  detail 
wherever  possible.  This  is  the  case  with  problems  of 
diet  for  the  foreign  born,  a  matter  of  great  practical 
importance  to  hospitals  and  to  health  workers  in  the 
homes.  So  also  with  the  urgent  and  picturesque  sub- 
ject of  the  medical  quack  and  his  all-too-effective 
methods  among  the  foreign  born. 

The  war  forced  Americanization  upon  the  public 
attention.  Some  developed  a  definite  conception  of 
Americanization  without  much  serious  thinking.  To 
them  it  meant  teaching  English  and  civics.  It  meant 
getting  the  immigrant  naturalized.  It  meant  making 
people  Americans  by  putting  them  through  certain 
instructions,  crowned  by  the  laying  on  of  hands. 

But  the  war  made  many  others  think  about  this 
matter.  It  brought  them  to  see  that  Americanization 
implies  more  than  mere  instruction  and  more  than 
naturalization.  The  assimilation  of  ten,  twenty,  or 
thirty  million  people  into  a  nation  of  over  one  hundred 
million  should  mean  mutual  understanding,  not  the 
swallowing  of  one  by  the  other.  A  common  language 
must  be  achieved,  but  also  mutually  respected  habits 
and  standards  of  life.  Full  Americanization  is  impos- 
sible without  an  all-round  transfusion  of  all  the  im- 
portant elements  in  human  life. 

Health  matters,  as  one  of  the  important  aspects  of 
life,  have  an  integral  part  in  the  process  of  Americani- 
zation.   The  numberless  habits,  customs,  standards, 

8 


THEORIES  VERSUS  PEOPLE 

upon  which  personal  and  family  hygiene  are  based 
are  of  importance  to  the  physician,  and  the  health  de- 
partment, in  relation  to  the  care  and  prevention  of 
disease.  They  are  also  everyday  elements  in  deter- 
mining the  extent  to  which  people  are  developing  as 
Americans,  members-in-full  of  an  American  com- 
munity. 

Have  people  such  habits  and  standards  of  house- 
hold life  that  if  good  housing  is  available  facilities 
will  be  used  and  not  misused  .^^  This  question  involves 
health  and  Americanization  at  the  same  time.  Do 
people  know  how  to  use  the  facilities  for  the  care  of 
disease,  such  as,  hospitals,  sanitariums,  clinics,  well- 
trained  private  doctors?  Or  are  people  too  ill  informed 
to  make  the  best  use  of  what  is  available?  This  is  not 
only  a  question  of  health.  It  involves  the  extent  to 
which  the  people  are  intelligent  participants  in  the 
American  community.  Are  people  intelligently  co- 
operative with  the  school  nurse,  with  the  department 
of  health,  the  infant  welfare  or  antituberculosis  agen- 
cies, public  or  private?  Are  people  subject  to  the 
exploitations  of  medical  quacks  because  of  ignorance 
of  good  medical  facilities  combined  with  inability  to 
read  English?  These,  again,  are  matters  of  both 
health  and  Americanization. 

Perhaps  the  chief  difficulty  in  such  a  study  as  this 

is  that  of  starting  with  a  clean  slate.   Too  many  people 

have  made  up  their  minds  concerning  Americanization 

before  thinking  about  it.    It  is  easy  to  be  led  into  a 

certain  policy  perhaps  unconsciously,  because  of  an  a 

priori  theory.    We  may  hold  in  the  backs  of  our  heads 

cherished  ideas  about  Americanization  or  about  the 

differences  between  races.    Consciously,  or  even  un- 

9 


IMMIGRANT  HEALTH  AND  COMMUNITY 

consciously,  we  may  have  prejudices  against  certain 
kinds  of  people.  Our  attitude  toward  Americaniza- 
tion may  be  deeply  injQuenced  also  by  a  fear  of  Bol- 
shevism. Our  selection  and  interpretation  of  facts, 
and  our  final  conclusions,  must  not  be  determined  by 
such  preconceptions. 

It  is  all  too  easy  to  let  race  prejudice  or  antagonism 
to  foreign  language  be  a  controlling  element  in  our 
judgments.  This  is  particularly  true  when  we  are 
hardly  conscious  of  our  prejudices.  It  is  well,  there- 
fore, to  discuss,  at  the  beginning,  the  three  prevailing 
groups  of  preconceptions  or  "theories"  about  Ameri- 
canization activities  from  the  point  of  view  of  medical 
and  health  work  especially.  Such  a  review  will  render 
,,us  conscious  of  the  place  and  limitations  of  each 
theory,  and  we  shall  be  less  likely  to  be  led  astray 
without  knowing  it. 

THE  BIG-STICK  THEORY 

"  Sorry  to  say  it,  but  most  of  them  must  be  scared  into 
doing  things."  Thus  tne  executive  of  a  Western 
health  organization  sums  up  his  policy  of  dealing  with 
them — the  foreign  born.  The  health  officer  of  a  large 
city  writes: 

In  most  cases  of  contagion  among  foreigners,  especially 
those  who  will  not  observe  quarantine,  we  keep  a  quarantine 
officer  in  the  neighborhood,  who  does  not  hesitate  to  arrest 
any  o£Pender,  and  generally  after  the  first  arrest  we  have  no 
further  trouble.  This  is  a  drastic  measure,  but  it  is  the 
only  efficient  one  we  know. 

A  surgeon  connected  with  a  large  industrial  estab- 
lishment says: 

10 


THEORIES  VERSUS  PEOPLE 

What  we  need  to  deal  with  the  health  problems  of  the 
foreign  born  is  adequate  health  laws  and  power  to  enforce 
them. 

A  health  officer  of  a  Middle  Western  city  of  mod- 
erate size  says: 

The  foreign  element  in  our  city  are  most  difficult  to  deal 
with  because  they  are  generally  inclined  to  help  themselves 
rather  than  accept  skilled  medical  assistance  and  advice. 

The  same  theory  as  that  expressed  in  the  previous 
quotations  appears  here  by  implication.  It  stands 
out  still  more  plainly  in  the  following,  from  a  child- 
welfare  bureau  in  a  large  Eastern  city: 

We  have  never  modified  the  type  of  work  to  suit  any 
special  groups  of  people.  We  have  always  attempted  to 
mold  the  groups  to  our  way,  so  that  our  work  would  be 
uniform.  We  do,  however,  teU  our  workers  never  to  en- 
croach upon  customs  of  different  nationalities,  if  those  cus- 
toms do  not  conflict  with  our  regulations  or  teaching. 

An  official  from  another  large  city  writes: 

In  hospitals  they  [the  foreign  born]  cannot  be  made  to 
understand  the  treatment,  and  do  not  seem  to  improve 
under  unfamiliar  conditions. 

A  devoted  worker,  himseK  of  foreign  extraction,  who 
has  spent  years  of  his  life  wrestling  with  this  problem 
in  great  hospitals,  illustrates  his  experience  as  follows: 

Internes,  as  a  rule,  wonder  how  Polish  mothers  can  be  for 
ten  years  in  America  without  knowing  the  language  of  the 
country.  My  answer  was  that  those  Polish  mothers  were 
exempted  by  the  United  States  government  by  having 
brought  forth  and  educated  ten  to  twelve  strong  and  healthy 
sons  and  daughters  that  are  able  to  speak  two  languages. 

11 


IMMIGRANT  HEALTH  AND  COMMUNITY 

But  our  social  workers  are  more  severe  in  their  judgment. 
In  their  fervor  they  would  like  to  call  upon  the  United 
States  army  and  navy  to  do  away  with  all  those  foreign 
languages. 

What  may  be  called  the  big-stick  theory  shows  its 
head  more  or  less  frankly  in  these  citations.  This 
theory  has  taken  on  new  vigor  because  of  the  war. 
Through  its  influence  the  continuance  of  foreign  cus- 
toms and  ideas  among  people  who  have  come  to  this 
country  has  been  made  to  appear  un-American  or  anti- 
American,  and  compulsion  has  been  recommended  as 
the  remedy.  These  ideas  find  almost  classic  expres- 
sion in  the  comic  paper's  recommendation  to  the  wor- 
ried mother  when  she  wished  to  know  how  her  children 
should  take  the  necessary  but  disagreeable  pills  pre- 
scribed by  the  doctor: 

How  should  they  take  'em? 

You  hold  their  noses. 

And  step  on  their  toeses. 
And  thus — you  make  'em. 

Analyzed  more  seriously,  the  big-stick  theory  seems 
to  imply: 

Americanism  as  a  dogma. 

Inferiority  (of  the  foreign  born)  as  a  datum. 

Uniformity  as  a  social  goal. 

Compulsion  as  a  method. 

Undoubtedly  a  large  number  of  persons  feel  that 
America  is  the  best  place  in  the  world — ^Americanism 
the  best  thing — and  they  then  proceed  to  the  con- 
clusion that  Americans  are  persons  like  themselves, 

12 


THEORIES  VERSUS  PEOPLE 

and  that  people  who  come  to  this  country  from  else- 
where ought  as  quickly  as  possible  to  make  them- 
selves, or  else  be  made,  like  Americans. 

In  health  work  the  application  of  the  big-stick 
theory  means  reliance  upon  police  power,  the  enforce- 
ment of  sanitary  regulations  by  punishing  people  who 
violate  them.  It  means  trying  to  educate  a  com- 
munity toward  better  sanitary  standards  by  telling 
people  w^hat  they  must  do  and  the  penalties  for  not 
doing  it.  There  are  those  who  consider  it  un-American 
to  use  foreign  languages  in  educational  or  health  work, 
regarding  this  as  a  concession  to  the  foreign  born 
which  is  unwarranted,  if  not  un-American. 

Many  big-stickers  would  protest  that  they  do  not 
hold  the  foreign  born  to  be  "inferior."  Often  a  belief 
in  inferiority  is  subconscious,  but  no  less  real.  Some- 
times it  appears  in  the  statement  that  the  immigrant 
has  no  right  to  retain  habits,  customs,  or  traditions 
which  he  brought  with  him  to  this  country.  Oftener 
it  is  apparent  when  men  are  called  "wops"  or 
"hunkies,"  or  in  the  mere  tone  in  which  immigrants 
are  referred  to.  How  does  such  a  theory  bear  com- 
parison with  the  Declaration  of  Independence? 

Every  important  social  group  believes  in  itself. 
The  conviction  that  "We  are  the  people  "  is  perhaps 
more  characteristic  of  Americans  than  of  others.  The 
wish  to  make  other  people  like  this  desirable  model  is 
a  natural  result.  It  takes  time  and  effort  to  perceive 
that  our  true  goal  is  not  uniformity,  but  unity;  not 
one  vast  note  of  blaring  sound,  but  a  harmony  of 
many  tones. 

No  sane  man  questions  the  necessity  of  authority 

and  of  its  use  under  certain  conditions.    The  strong 

13 


IMMIGRANT  HEALTH  AND  COMMUNITY 

hand  of  the  law  must  and  should  deal  with  the  care- 
less consumptive  who  endangers  his  wife  and  children 
by  promiscuo  us  spitting  about  his  home ;  the  infectious 
syphilitic,  recalcitrant  to  treatment  and  persistent  in 
evil  courses;  or  the  family  which  maintains  a  gross 
sanitary  nuisance.  In  such  extreme  cases  the  course 
of  policy  is  clear.  But,  as  a  rule,  it  is  important  to 
determine  the  degree  of  authority  which  proves  effec- 
tive in  securing  results. 

Is  it  best  to  teach  by  compulsion?  When?  How? 
Or  do  we  get  better  results  by  some  other  method? 
The  question  at  issue  is  not  the  presence  or  absence 
of  the  principle  of  authority  from  the  armamentarium 
of  medical  or  health  work,  but  the  manner  and  extent 
in  which  this  instrument  proves  effective  as  compared 
with  other  means. 

The  use  of  compulsion  as  a  method  is  one  of  those 
questions  of  degree  which  amount,  in  practice,  to 
questions  of  principle.  No  sensible  man  objects  to 
the  proclamation  of  martial  law  under  certain  condi- 
tions. Martial  law  has  its  place  among  the  instru- 
ments which  a  wise  society  will  have  at  its  command 
for  use  when  necessary.  But  under  what  conditions 
is  it  necessary?  How  often?  How  much?  Would  we 
wish  to  live  in  a  society  in  which  martial  law  was  the 
habitual  method  of  administration?  If  not,  let  us  seek 
to  define  its  place,  so  that  we  shall  know  where  and 
when  to  employ  it,  and  when  and  where  to  avoid  it. 

If  we  proceed  in  medical  or  health  work  with  the 

big-stick  theory  under  our  caps,  we  are  likely  to  adopt 

policies  and  methods  because  we  think  they  ought  to 

work,  without  constantly  testing  them  to  see  how 

they  do  work.     Doubtless  we  all  wish  to  attain  a 

14 


THEORIES  VERSUS  PEOPLE 

unified,  harmonious  community,  with  high  standards 
of  persocal  and  public  hygiene.  What  is  the  best 
method  of  attainment?  The  test  of  method  in  medi- 
cal or  health  work  is  the  same  as  in  any  other  field  of 
practical  endeavor.  Policies  and  methods  must  be 
tested  by  results. 

The  big-stick  theory  ought  to  be  applied  just  as 
far  as  it  will  work — in  a  democratic  society.  And  how 
far  it  will  work  is  to  be  determined  not  by  our  pre- 
conceptions of  policy,  not  by  an  a  priori  theory  of 
Americanization,  but  by  the  dispassionate  study  of 
principles  and  the  practical  test  of  facts. 

THE   LAISSEZ-FAIRE   THEORY 

The  traditional  American,  when  not  under  pressure 
of  war  or  the  dread  of  some  social  upheaval,  is  an 
energetic  individualist.  He  sees  a  chance  to  push 
himself  ahead,  and  he  admits  the  other  fellow's  right 
to  the  same  opportunity.  He  follows  the  principle, 
live  and  let  live,  which  in  application  to  health  work 
can  best  be  expressed  by  the  reverse,  die  and  let  die. 
The  laissez-faire  theory  is  based  partly  on  the  op- 
timism of  ignorance.  The  belief  is  briefly  as  follows. 
The  immigrants  who  have  "the  stuff"  in  them  take 
care  of  themselves  and  become  "Americans"  without 
any  great  diflSculty.  The  incapable  must  be  taken 
care  of  anyway.  America  is  the  world's  melting  pot. 
All  varieties  of  the  human  species  have  come  here. 
The  melting  pot  transforms  all  into  Americans,  like 
us  who  were  born  here.  A  piece  of  the  philosopher's 
stone  is  always  somewhere  in  the  crucible,  and  turns 

every  good  bit  of  alloy  into  American  gold. 

15 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Frequent  as  are  contemporary  expressions  of  the 
big-stick  theory  of  Americanization  among  medical 
and  health  workers,  still  more  frequent  expressions 
indicate  the  attitude  of  laissez  faire. 

**I  hardly  think  it  desirable  to  work  out  special 
diets  for  foreigners,"  writes  the  chief  of  dietetics  in  a 
large  city  hospital,  "for  I  am  told  by  the  nurse  that 
they  do  not  complain  of  the  meals  served." 

"This  state  has  a  large  number  of  immigrants  of  all 
nationalities.  We  are  not  making  any  special  effort 
to  reach  these  people  other  than  publishing  certain 
literature  in  their  native  language,"  says  the  head  of 
a  state  department  of  health. 

The  limitation  in  some  cases  of  this  kind  is  lack  of 
funds  rather  than  lack  of  desire,  but  many  evidently 
feel  with  the  health  department  of  a  large  Middle 
Western  city,  that  "Our  foreign  population  is  not  a 
problem  in  any  sense." 

In  application  to  health  work  the  laissez-faire  theory 
is  illustrated  by  the  health  department,  which  pro- 
vides various  facilities,  which  is  ever  seeking  larger 
funds,  but  which  expects  people  to  seek  out  what  is 
provided.  Investigations  to  determine  what  needs 
exist  are  rarely  undertaken  where  this  point  of  view 
dominates,  nor  are  districts  surveyed  to  discover  what 
groups  of  people  have  or  have  not  been  reached  by 
antituberculosis  or  infant- welfare  campaigns.  Neither 
is  it  likely  that  those  imbued  with  this  easy  point  of 
view  will  consider  the  foreign  born  as  a  special  prob- 
lem, the  study  of  which  is  necessary  in  order  to  de- 
termine effective  policies  and  methods. 

"We  object,"  said  a  health  officer  of  a  large  city 

department,  "to  giving  any  special  consideration  to 

16 


THEORIES  VERSUS  PEOPLE 

the  health  problems  of  the  foreign  born.  This  would  be 
discrimination.    Our  aim  is  to  treat  everybody  alike." 

In  almost  the  same  words  the  superintendent  of  a 
large  hospital  stated  his  policy.  These  people  remind 
one  of  the  Dutch  judge  who  said  that  it  always 
troubled  him  to  hear  both  sides  of  a  case.  It  is  easy 
to  proceed  upon  the  supposition  that  everybody  is 
alike  or  near  enough  alike  for  practical  purposes. 
Have  in  mind  a  standard.  Consequently,  have  your 
scheme  of  sanitation  or  education  or  medical  care. 
Maintain  your  standard.  Offer  your  scheme.  Let 
those  who  come  to  be  benefited  by  the  work  profit 
by  its  blessings. 

The  laissez-faire  theory,  as  applied  to  the  field  of 
medical  or  health  work,  means  the  assumption  that 
the  foreign  born  have  no  special  health  problems  and 
that  methods  of  health  work  need  not  be  specially 
adapted  to  immigrant  characteristics  or  needs. 

No  sensible  person  will  question  the  value  of  throw- 
ing the  responsibility  for  a  man's  success  upon  him- 
self, or  of  expecting  that  those  who  wish  to  be  blessed 
should  seek  the  places  of  blessing.  But  here  again 
the  test  of  theory  must  be  by  results.  The  danger  is 
that  we  mingle  our  prejudices  with  our  practice  in- 
stead of  guiding  our  practice  and  controlling  our 
prejudices  by  constant  tests  of  efficiency  in  getting 
results. 

In  the  descriptive  portions  of  this  book  evidence 

will  be  presented  to  show  that  the  presupposition  of 

uniformity  on  which  the  laissez-faire  theory  is  based 

is  not  correct.    We  shall  endeavor  to  demonstrate  that 

differences  in  health  problems  between  native  and 

foreign  born  exist,  sufficient  to  warrant  practical  con- 

17 


IMMIGRANT  HEALTH  AND  COMMUNITY 

sideration;  and  that  there  are  even  wider  differences 
in  psychological  and  social  reactions  between  native 
and  foreign  born  which  necessitate  careful  adaptation 
of  methods  to  each  group  in  order  to  secure  the  best 
results  in  medical  or  health  work. 

The  laissez-faire  theory  is  a  useful  corrective  to  the 
overeagerness  of  some  reformers,  but  it  is  too  simple 
to  be  true.  As  the  Yankee  who  did  not  like  French, 
translated  it,  the  laissez-faire  theory  is  a  lazy  theory, 
and  not  fair. 

THE   DEMOCRATIC   THEORY 

A  new  conception  has  taken  practical  shape  in 
health  work  during  recent  years  which  we  may 
call  the  100-per-cent  Idea.  Suppose  one  thousand 
babies  a  year  are  born  in  a  certain  community.  Sup- 
pose there  is  a  bureau  of  child  hygiene  of  the  local 
department  of  health,  or  a  private  association  doing 
infant-welfare  work.  Suppose  the  baby  clinic  or 
infant- welfare  station  had  an  attendance  of  one  hun- 
dred and  fifty  different  babies  during  the  course  of  a 
year.  How  then  shall  the  bureau  of  child  hygiene  or 
the  infant- welfare  association  measure  its  results.? 

They  may  compare  the  death  rates  up  to  one  year 
of  age  among  the  one  hundred  and  fifty  babies  reached 
with  the  corresponding  death  rate  among  babies  in 
the  community  at  large.  They  may  take  pride  if  a 
reduction  is  shown.  But  if  they  have  the  100- 
per-cent  Idea  in  mind  they  will  also  be  humble, 
because  they  have  reached  only  15  per  cent  of  the 
community's  babies.  Their  measurements  of  results 
will  thus  be  more  modest.    Their  program  for  future 

effort  will  be  expanded. 

18 


THEORIES  VERSUS  PEOPLE 

Possibly  these  people  feel  that  the  most  needy 
babies  were  the  very  15  per  cent  which  their  work 
reached;  but  that  cannot  be  told  without  a  canvass, 
a  survey,  of  all  the  babies.  Funds  may  not  permit 
the  w^ork  to  reach  100  per  cent.  A  certain  proportion 
of  parents  may  be  too  well  to  do  to  wish  to  have  their 
babies  "reached."  But  after  all  it  is  the  principle  on 
which  the  infant  -  welfare  work  proceeds  that  will 
determine  its  quality,  its  program,  and  the  extent  to 
which  it  ultimately  realizes  its  program.  The  100- 
per-cent  Idea  sets  the  goal  and  furnishes  a  yardstick 
for  measuring  annually  the  steps  toward  ultimate 
attainment. 

A  recent  development  in  health  work,  which 
embodies  the  100-per-cent  Idea,  is  the  health 
center.  Essentially,  the  health  center  is  an  endeavor 
"to  do  things  for  everybody  and  to  do  things  together, 
within  a  given  district."  In  various  forms  these  cen- 
ters are  being  established  throughout  the  country  in 
increasing  numbers.  Previous  to  the  war  such  cities 
as  Philadelphia,  New  York,  Pittsburgh,  Cleveland, 
Cincinnati,  Boston,  Dayton,  and  others,  had  them  in 
one  form  or  another.  The  war  necessarily  interrupted 
progress,  but  its  final  eflPect  has  been  a  vast  stimulant 
to  medical  and  health  work  in  almost  all  forms,  the 
health  center  included. 

In  the  cities  and  towns  where  health  centers  have 

been  established  the  details  have  varied  greatly.    The 

idea  of  co-ordinating  local  health  activities  has  been 

prominent  in  some.    Infant-welfare  stations,  prenatal 

cliuics,  tuberculosis  clinics,  dental  clinics,  w4th  their 

related    medical    and    nursing    services,    have    been 

brought  together  within  a  single  building.    Sometimes 

19 


IMMIGRANT  HEALTH  AND  COMMUNITY 

various  other  kinds  of  medical,  educational,  or  philan- 
thropic work  have  been  brought  within  the  center. 

The  idea  of  confining  effort  to  a  definite  area  and 
of  doing  intensive  work  for  that  area  is  also  a 
characteristic  feature  of  the  health-center  move- 
ment. The  100-per-cent  Idea  requires  localization  at 
the  present  stage  of  progress,  where  it  is  rarely  possible 
to  secure  enough  funds  to  reach  a  whole  community 
intensively.  Localization  has  brought  with  it  a  more 
intimate  adaptation  of  the  medical  and  health  work 
to  the  needs  of  the  neighborhood,  with  its  various 
economic,  racial,  and  other  characteristics.  It  has 
necessitated  the  co-operation  of  individuals  within  the 
district,  or  of  local,  racial,  social,  fraternal,  or  other 
organizations.  The  utilization  of  psychological  and 
social  elements,  as  well  as  points  of  medical  technique, 
is  suggested,  stimulated,  and  developed  by  the  driv- 
ing force  of  the  100-per-cent  Idea. 

A  characteristic  feature  of  the  majority  of  health 
centers  has  been  location  in  a  district  largely  peopled 
by  foreign  born.  In  some  cases  the  work  is  in  an  area 
where  the  great  majority  of  the  population  are  of  a 
single  race  or  national  group.  The  health  center 
started  in  1915  by  the  New  York  Health  Department 
was  in  the  Jewish  district  of  the  lower  East  Side. 
The  center  of  the  Bowling  Green  Neighborhood  Asso- 
ciation is  in  a  section  largely  Syrian.  In  Cleveland 
one  health  center  is  in  the  Hungarian  section;  one 
amidst  Poles  and  other  Slavs;  others  among  mixed 
populations.  Many  other  illustrations  could  be  cited 
of  health  centers  in  areas  inhabited  by  foreign  born 
from  different  national  or  race  groups,  now  one  and 

now  another  predominating. 

20 


THEORIES  VERSUS  PEOPLE 

No  one  imbued  with  the  big-stick  theory  would 
start  a  health  center  if  he  realized  what  he  was 
about.  The  100-per-cent  Idea  requires  a  study  of 
community  needs,  a  canvass  or  survey  of  the  district, 
and  an  appeal  for  local  co-operation,  such  as  can 
hardly  be  achieved  by  the  use  of  mere  authority.  The 
health  center  is  by  no  means  the  only  manifestation 
of  the  democratic  theory  in  medical  and  health  work, 
but  a  real  health  center  can  only  exist  where  there  is 
a  democratic  idea  in  mind  and  an  effort  toward 
realizing  it. 

Some  of  the  success  of  medical  and  health  work 
depends  upon  the  judicious  use  of  authority,  but  more 
depends  upon  effective  education.  Much  of  the 
efficiency  of  a  physician,  a  hospital,  or  a  dispensary, 
in  curing  disease,  depends  upon  how  fully  the  patient 
understands  the  medical  man's  directions  and  advice. 
In  the  case  of  chronic  disease  the  educational  element 
is  of  the  greatest  importance,  because  old  life  habits 
must  often  be  changed  and  new  ones  developed.  In 
an  acute  disease  the  educational  element  is  sometimes 
less  obvious,  but  it  is  always  present,  especially  during 
the  period  of  convalescence.  In  all  branches  of  disease 
prevention,  the  intelligent  co-operation  of  the  people 
is  the  greatest  single  element. 

The  diminution  of  tj'phoid  fever  in  a  city,  through 
an  improved  water  supply,  depends  on  public  support 
for  the  necessary  financial  appropriations.  Consider- 
able sections  of  a  community  may  participate  little 
in  such  an  educational  campaign  and  yet  benefit  by 
its  results.  But  in  the  efforts  against  tuberculosis, 
infant  mortality,  the  deaths  and  disabilities  from 
child-bearing,  the  venereal  diseases,  cancer,  the  de- 
3  21 


IMMIGRANT  HEALTH  AND  COMMUNITY 

generative  diseases  of  middle  life,  success  depends 
fundamentally  upon  the  extent  to  which  the  under- 
standing co-operation  of  individuals  can  be  secured. 

Education  is  the  foundation  of  success  in  these 
endeavors.  Knowledge  of  the  nature  of  various  dis- 
eases, their  modes  of  spread,  and  the  methods  of  pre- 
venting infection,  should  be  continuously  sought.  But 
a  mass  of  existing  knowledge  is  already  on  hand, 
waiting  application  to  large  groups  in  every  commu- 
nity. Yet  this  knowledge  lies  fallow  because  too  few 
of  the  people  have  been  educated  to  understand  the 
benefits  that  would  follow  its  application  and  there- 
fore to  support  the  steps  necessary  to  it. 

We  cannot  educate  with  a  hammer.  The  ruler  has 
been  abandoned  as  the  chief  instrument  in  educating 
children.  The  principle  of  interest  is  now  the  guide, 
not  the  principle  of  compulsion.  This  is  still  more 
true  with  adults.  With  them  interested  participation 
is  essential  to  success.  There  must  be  a  motive  which 
creates  interest,  and  a  method  on  the  part  of  the  edu- 
cator which  maintains  this  interest  and  develops  it. 
During  the  course  of  this  study  the  most  characteris- 
tic examples  of  successful  health  work  with  the  foreign 
born  are  found  to  be  closely  connected  with  the  prin- 
ciples of  local  co-operation  and  adaptation  to  com- 
munity needs. 

In  its  application  to  medical  and  health  work  the 
democratic  theory  requires  that  the  physician,  the 
health  officer,  the  executive,  the  nurse,  and  the  social 
worker  must  study  people  as  well  as  technique.  They 
must  discover  how  far  differences  among  people  or 
between  different  groups  of  people  require  differences 
in  methods,  and  what  these  differences  are.    A  ready 

22 


THEORIES  VERSUS  PEOPLE 

answer  to  these  questions  can  spring  forth  from  one's 
preconceptions.  An  answer  more  difficult  of  attain- 
ment, but  far  nearer  the  truth,  will  emerge  from  the 
study  of  people  combined  with  an  examination  of 
practical  results. 

The  results  must  be  judged  by  the  proportion  of 
the  population  reached  as  well  as  by  the  effectiveness 
of  methods  upon  those  who  are  reached.  Then  the 
participation  of  individuals  and  of  organizations  will 
be  enlisted  locally  or  generally  in  a  common  effort  for 
higher  standards  of  health  and  of  happy,  efficient 
living.  Then  the  health  program  will  infuse  itself  into 
the  program  of  Americanization,  for  these  same  prin- 
ciples are  the  right  foundation  of  the  general  Ameri- 
canization program. 

Both  in  their  application  to  the  program  of  Ameri- 
canization and  also  to  the  procedures  of  medical  and 
health  work,  the  principles  of  this  chapter  are  based 
upon  the  idea  that  Americanism  is  not  a  quality,  but 
an  achievement.  Its  attainment  must  be  through 
participation  in  a  many-sided  community  life,  in  which 
individuals  of  all  racial  origins  shall  share,  and  to 
which  each  shall  contribute. 

People  learn  to  adapt  themselves  to  the  common 
life  chiefly  by  participation  in  some  aspect  of  this  life 
as  individuals  or  as  members  of  some  organization. 
The  agencies  of  government,  and  all  organized  co- 
operative activities  for  mutual  benefit,  must  be  adapted 
to  serve  individual  needs.  The  principle  of  authority 
must  be  given  its  place,  but  the  principle  of  democ- 
racy must  dominate  it.  Then  the  mutual  respect  of 
individuals  for  one  another  will  maintain  freedom, 
while  the  sense  of  a  common  purpose  will  sustain  law. 

23 


Part  II 

IMMIGRANT  CONDITIONS  AND 
POINTS  OF  VIEW 


n 

SICKNESS   AMONG   THE    FOREIGN   BORN 

Many  times  the  question  has  been  asked:  "What 
makes  you  think  there  is  a  health  problem  of  the 
immigrant  apart  from  that  of  the  native  born?  What 
statistics  have  you  to  indicate  any  such  thing?  "  That 
is  a  difficult  question  to  answer,  for  there  is  a  gi'ave 
lack  of  statistical  data,  including  racial  factors.  We 
know  that  sickness  is  a  serious  handicap  to  all  workers, 
affecting  native  as  w^ell  as  foreign  born.  There  is  a 
general  unanimity  among  the  various  studies  that 
have  been  made  as  to  the  loss  of  time  through 
sickness. 

The  U.  S.  Commission  on  Industrial  Relations, 
1915,  estimated  that  "each  of  the  thirty -odd  million 
wage  earners  in  the  United  States  loses  on  the  average 
nine  days  a  year  through  sickness."  This  estimate 
corresponded  closely  to  the  statistical  evidence  from 
health-insurance  systems  abroad. 

Since  the  report  of  this  commission  appeared,  a 
number  of  studies  have  been  conducted  in  the  United 
States,  and  the  estimate  has  been  substantially  con- 
firmed.^ Thus  in  the  seven  sickness  surveys  made  by 
the  Metropolitan  Life  Insurance  Company  among 

^  Margaret  Loomis  Stecker,  Some  Recent  Morbidity  Data,  p.  22, 
Table  VII. 

27 


IMMIGRANT  HEALTH  AND  COMMUNITY 

its  industrial  policy-holders,  the  average  disabling 
sickness  for  each  of  the  376,573  persons  over  fifteen 
years  of  age  was  8.4  total  days,  or  6.9  working  days, 
per  year.  The  recent  study  of  some  40,000  members 
of  the  Workmen's  Sick  and  Benefit  Fund  of  America, 
conducted  by  the  Federal  Bureau  of  Labor  Statistics, 
showed  an  annual  average  per  member  of  6.6  days  of 
disability.^  The  number  of  days  of  sickness  would,  of 
course,  be  somewhat  larger.  Both  the  Ohio  and 
Illinois  health  commissions  estimated  the  average  loss 
to  be  between  8  and  9  days. 

THE    BURDEN   OF   SICKNESS 

But  the  burden  of  illness  is  not  expressed  by  the  num- 
ber of  days  lost  by  the  average  wage  earner.  Some 
people  are  hardly  ever  sick,  and  during  any  given  year 
only  a  certain  percentage  of  persons  fall  sick.  The 
problem  arises  because  there  is  sufficient  illness  among 
this  certain  percentage  of  persons  to  cause  serious  loss, 
suffering,  breakdown  of  ability  for  self-support,  and 
breakup  of  families.  What  we  practically  need  to 
know  is  the  amount  and  extent  of  sickness. 

The  Ohio  Health  Insurance  and  Old  Age  Pension 
Commission,  in  a  study  of  663,163  members  of  benefit 
societies;  the  Illinois  Health  Insurance  Commission,  in 
an  investigation  of  4,474  wage  earners  in  Chicago ;  and 
the  Pennsylvania  Commission,  in  a  study  of  743  fami- 
lies, including  3,198  individuals,  of  which  1,341  were 
workers — have  thrown  light  on  this  subject.    Both  the 


1"  Disability  Among  Wage  Earners,"  Monthly  Labor  Review, 
November,  1919,  Bureau  of  Labor  Statistics,  U.  S.  Department 
of  Labor. 

28 


SICKNESS  AMONG  THE  FOREIGN  BORN 

Illinois  and  Ohio  commissions  estimated  that  about 
one  worker  in  five  lost  more  than  a  week's  work 
through  sickness.  If  20  per  cent  of  all  workers  suffer 
loss  from  this  cause,  the  amount  of  sickness  is  found 
to  be  considerable.  The  average  loss  of  time  of  all 
sick  persons  is  estimated  by  the  Illinois  commission 
to  be  more  than  50  days  a  year,  and  by  the  Pennsyl- 
vania commission  to  be  about  40  days. 

It  must  also  be  held  in  mind  that  the  family  of 
small  income  suffers  most.  In  another  study  by  the 
Illinois  commission  of  a  number  of  such  families 
(comprising  3,475  persons),  about  four  out  of  five 
suffered  from  sickness  of  the  wage  earner.  Sickness 
of  other  members  of  the  family  added  to  the  difficulty 
in  more  than  two  thirds  of  these  cases.  So  it  can  be 
seen  that  sickness  is  a  considerable  handicap  to  the 
wage  earners  of  the  country,  and  especially  to  those 
getting  the  lower  wages,  large  numbers  of  whom  are 
immigrants. 

Is  the  burden  of  sickness  heavier  among  the  foreign 
born  than  among  native  Americans.^  The  evidence 
varies  with  race  and  with  disease,  but  on  the  whole  it 
is  apparent  that  the  immigrant  bears  at  least  as  heavy 
a  burden  from  sickness  as  does  the  native.  Further- 
more, the  financial  ability  of  the  foreign  born  is  gen- 
erally less.  Through  the  co-operation  of  Profs.  H.  A. 
Millis  and  Ernest  W.  Burgess,  of  the  staff  of  the 
Illinois  Health  Insurance  Commission,  it  was  possible 
to  make  an  analysis  of  about  12,000  cases.  In  several 
respects  the  data  are  not  complete,  but  for  the  pur- 
poses of  comparing  duration  of  sickness  of  the 
native  and  foreign  born  the  following  table  is  fairly 

reliable : 

29 


IMMIGRANT  HEALTH  AND  COMMUNITY 

TABLE  I 

Relative  Duration  of  Illness  Among  2,385  Native  and  9,211 
Foreign-born  White  Persons  Over  Fourteen  Years  of 
Age,  Studied  by  the  Illinois  Health  Insurance  Com- 
MissioN.i  (Eight  Hundred  and  Fifty-four  Negroes 
Studied — Making  Total  of  12,450) 


DuBATioN  OF  Illness 

Native  White 

Foreign-born 
White 

Number 
111 

Per  Cent 
of  All  111 

Number 
111 

Per  Cent 
of  All  111 

Less  than  one  week 

One  week 

3 
54 
62 
32 
31 

182 
57 
23 
49 

115 

0.7 

12.7 

14.6 

7.5 

7.3 

42.7 
13.4 
5.4 
11.5 
27.0 

2 

104 

164 

93 

96 

459 
183 
83 
151 
404 

0.2 
8.1 

Two  weeks 

12.8 

Three  weeks 

7.3 

Four  weeks 

7.5 

One  month  or  less 

35.9 

One  to  two  months 

14.3 

Two  to  three  months 

Twelve  to  fifty-three  weeks . 
Chronic  illness 

6.5 
11.8 
31.6 

Total 

426 

100.0 

1,280 

100.0 

It  would  appear  from  this  table  that  the  proportion 
of  illnesses  of  long  duration  is  somewhat  larger  among 
the  foreign  born  of  these  Chicago  families  than  among 
the  native  born.  The  difference  of  the  per  cents 
shown  in  chronic  illnesses  and  those  of  a  month  or 
less,  point  in  this  direction  and  are  apparently  larger 
than  would  be  accounted  for  by  statistical  errors. 

Of  course,  no  general  conclusions  can  be  drawn 
from  a  single  small  survey  of  this  type;  the  data  must 
be  taken  for  what  they  are  worth,  and  are  presented 
largely  to   suggest  that   the  elements   of   race   and 

1  Illinois  Health  Insurance  Commission,  data  furnished  by- 
Burgess. 

30 


SICKNESS  AMONG  THE  FOREIGN  BORN 

nationality  be  included  in  succeeding  sickness  surveys. 
Results  of  considerable  interest  may  be  expected  at  a 
comparatively  small  additional  cost  of  time  and  effort. 
There  are  other  data  that  throw  light  on  morbidity  of 
the  foreign  born  and  answer  some  important  questions. 

GENERAL   MORBIDITY   STATISTICS 

Probably  the  most  far-reaching  investigation  which 
has  compared  the  physical  fitness  of  the  native  and 
foreign  born  is  that  made  by  the  War  Department  in 
selecting  drafted  men  for  the  army.  The  large  num- 
bers involved  make  the  results  reliable.  To  under- 
stand the  statistics  which  are  here  cited  it  is  necessary 
to  know  the  definitions  which  the  War  Department 
gave  to  Groups  A  and  D  among  the  men  examined.'^ 

Group  A  was  composed  of  men  who  are  vigorous  and  with- 
out any  physical  defect  which  might  interfere  with  the  full 
performance  of  military  duties.  Group  D  contained  those 
who  were  found  to  have  conditions  which  unfitted  them  for 
military  service.  This  last  group  was  made  up  in  large  part 
of  those  imfit  also  for  most  civilian  occupations. 

Later  m  the  report  it  is  stated  that:^ 

For  the  purpose  of  comparing  the  physical  qualifications 
of  natives  and  aliens,  a  comparison  was  made  of  the  rejec- 
tions in  local  boards  composed  dominantly  of  natives  and 
aliens,  respectively.  Some  85,000  examinations  were  assem- 
bled from  local  boards  in  dominant  alien  wards  of  the  cities 


^  Second  Report  of  the  Provost  Marshal  General  to  the  Secretary 
of  War  on  the  Operations  of  the  Selective  Service  System  to  De- 
cember 20,  1918,  pp.  152-153. 

Ubid.,  pp.  160-161. 

31 


IMMIGRANT  HEALTH  AND  COMMUNITY 

of  New  York,  Philadelphia,  Chicago,  Cleveland,  Milwaukee, 
and  Cincinnati,  representing  a  registration  of  300,000.  Then 
some  100,000  examinations  were  similarly  assembled  from 
other  than  city  boards  in  the  states  of  Indiana,  Iowa,  Kan- 
sas, Kentucky,  and  Ohio,  representing  also  a  registration 
of  300,000.    The  results  were  as  follows: 


TABLE  II 

Phtsical  Rejections  in  Alien  and  Native  Communities 

Compared 


Alien  and  Native  Physical  Rejections 
Compared 


1.  Total  number  of  records  of  examinations 

compared  in  dominant  alien  and  native 
communities 

2.  Rejected  (Group  D) 

3.  Total  compared,  alien  communities. . .  . 

4.  Rejected  (Group  D) 

5.  Total  compared,  native  communities 

6.  Rejected  (Group  D) 


Number 

Per  Cent 

OF 

Rejections 

184,854 

28,184 

15.25 

84,723 



14,525 

17.14 

100,131 

13,659 

13.64 

It  is  interesting  to  note  that,  as  might  be  expected,  this 
comparison  is  greatly  to  the  advantage  of  the  native  Ameri- 
cans. In  every  100,000  men  the  native  born  would  yield 
3,500  more  (an  additional  regiment  at  war  strength)  for 
military  service  than  would  a  like  number  of  foreign  born. 


Although  issue  might  be  taken  with  the  statement 
that  there  is  "great  advantage"  to  the  native  Ameri- 
cans in  the  comparison,  it  is  apparent  that  there  is  a 
substantial  difference  between  the  per  cent  of  rejec- 
tions in  native  and  alien  communities. 

An  additional  light  on  this  subject  is  thrown  by  a 

report  from  local  board  for  Division  No.  129,  New 

York  City.    This  board,  realizing  a  great  opportimity, 

32 


SICKNESS  AMONG  THE  FOREIGN  BORN 

made  careful  anthropometric  studies  of  about  600 
registrants.    A  preliminary  report  said:^ 

Time  has  been  lacking  for  a  final  study  of  the  observed 
data.  However,  the  figures  seem  to  indicate  that  the  foreign- 
born  registrants  were  markedly  less  fit  for  service  than  the 
native  born. 

Since  this  report  was  written  this  local  board  has 
gone  farther  into  the  matter  and  summarized  certain 
results  which  verify  these  preliminary  conclusions:^ 

While  the  following  data  are  based  on  a  relatively  few  cases 
(397)  the  differences  are  too  great  to  be  considered  mere 
accidental  difiFerences.  They  are  real  mathematical 
differences. 

TABLE  III 

Report  of  Physical  Examinations  on  Drafted  Men  in  Local 
Board  129,  New  York  City,  1919 


Class  A 

Class  B 

Class  C 

Class  D 

03 

Physi- 
cally Fit 

Remedial 
Defects 

Limited 

Service 

Rejected 

^ 
^ 

Num- 
ber 

Per 

Cent 

Num- 
ber 

Per 

Cent 

Num- 
ber 

Per 

Cent 

Num- 
ber 

Per 

Cent 

Num- 
ber 

Foreign  born 

American  born: 

Foreign  parents. . 

Mixed  parents . . . 

American  parents 

34 

42 
43 
92 

37.0 

46.1 
64.2 
62.6 

4 

3 
2 

4 

4.3 

3.3 
3.0 
2.7 

35 

25 
16 
20 

38.0 

27.5 
23.9 
13.6 

19 

21 

6 

31 

20.7 

23.0 

9.0 

21.1 

92 

91 
67 

147 

Total  series 

211 

53.1 

13 

3.3 

96 

24.2 

77 

19.4 

397 

^  Second  Report  of  the  Provost  Marshal  General  to  the  Secretary 
of  War  on  the  Operations  of  the  Selective  Service  System  to 
December  20,  1918,  pp.  160-161. 

2  Dr.  Louis  R.  Sullivan,  American  Museum  of  Natural  History, 
Analysis  of  Data  Furnished  by  Local  Board  129,  New  York  City, 
July  14,  1919.     (Manuscript.) 

33 


IMMIGRANT  HEALTH  AND  COMMUNITY 

In  Class  A,  which  mcluded  all  men  who  are  physically  fit, 
we  find  a  greatly  increasing  percentage  of  men  falling  in 
this  class  as  we  pass  from  foreign  born,  and  American  born 
of  foreign  parents,  to  American  born  of  mixed  and  native 
parents.  These  two  latter  groups  are  well  above  the  average 
for  the  total  series,  while  the  two  former  are  considerably 
below  this  average. 

Class  B  is  of  little  significance  since  it  included  only  those 
with  minor  defects. 

Class  C  included  all  men  with  a  defect  serious  enough  to 
be  an  impediment  in  general  military  work,  but  not  neces- 
sarily in  some  special  vocation.  Here  the  percentage  de- 
creased from  the  foreign  born  to  the  American  born  of 
American  parentage. 

In  Class  D,  which  included  all  men  with  some  defect 
serious  enough  to  incapacitate  them  for  all  military  service, 
and  probably  also  most  civilian  vocations,  we  find  small 
differences,  yet  these  differences  favor  the  Americans  of 
mixed  or  American  parentage. 


MORBIDITY   OF  SPECIAL  RACES 

Considering  how  scant  are  morbidity  data  of  any  sort 
in  the  United  States,  we  are  fortunate  in  being  able 
to  present  original  figures  from  the  Henry  Street 
Settlement  in  New  York  City,  relative  to  illness  among 
the  Italians  and  Hebrews.  These  two  races  predomi- 
nate in  the  districts  surrounding  the  settlement.  Care- 
ful record  by  race  was  kept  in  1916  of  the  cases  of  ill- 
ness visited  by  the  nurses  from  the  settlement.  The 
17,380  cases  were  tabulated  according  to  race,  disease, 
deaths,  and  age  distribution.  The  table  given  on  the 
following  page  is  made  up  from  the  full  report. 

When  statistics  are  gathered  for  such  a  considerable 
number  of  cases  racial  differences  become  apparent. 
There  is  a  heavy  incidence  of  respiratory  diseases  upon 


SICKNESS  AMONG  THE  FOREIGN  BORN 


hI 

►t 

H 

il 

1 

£- 

( 

GD    O 

3 

< 

pS 

e* 

( 

'*  n 

O 

s  o 

P 

CL«. 

^— 

S.£. 

s 
p 

■  o. 

o' 

m 

B 

IMMIGRANT  HEALTH  AND  COMMUNITY 

the  Italians.  Although  they  represent  only  one  in 
every  five  people  attended  for  any  form  of  sickness, 
about  two  out  of  every  five  respiratory  cases  were 
Italians.  This  high  per  cent  is  found  in  each  Italian 
age  group,  being  highest  for  the  groups  between  one 
year  and  six. 

DIAGRAM  2. — PROPORTION  OF  PNEUMONIA  AND  OTHER  RE- 
SPIRATORY CASES  TO  ALL  CASES  ATTENDED  BY  HENRY 
STREET   SETTLEMENT  NURSES 

1. 


In  the  mortality  from  all  respiratory  cases  we  find 
a  striking  difference  between  Jews  and  Italians.  The 
Jews  have  a  per  cent  of  2.6  and  the  Italians  of  8.9. 
Among  children  under  one  year  only  5.7  per  cent  of 
Jewish  children  died  as  compared  to  17.7  per  cent  of 
Italian. 

HIGH   MORBIDITY   OF  ITALIANS 

The  high  rate  of  morbidity  and  mortality  of  Italians, 
both  children  and  adults,  is  attested  by  several  other 
studies. 

Dr.  Donald  B.  Armstrong,  in  a  recent  article  about 
influenza,^  spoke  of  the  high  morbidity  rate  from  this 
disease  and  from  pneumonia  among  the  Italians  in 
Framingham,  Massachusetts.  He  found  there  that 
the  Italians  had  suffered  from  a  rate  four  times  that 
of  the  rest  of  the  population,  which  was  chiefly  Irish. 

^D.  B.  Armstrong,  M.D.,  Boston,  "Influenza:   Is  It  a  Hazard 
to  Be  Healthy?  "  Medical  and  Surgical  Journal,  January,  1918,  p.  65. 

36 


SICKNESS  AMONG  THE  FOREIGN  BORN 

The  prevalence  of  malnutrition  and  rickets  among 
the  Italians  is  strongly  verified  by  the  experience  of 
numerous  health  agencies.  In  the  investigation  of 
the  physical  welfare  of  1,400  school  children.  New 
York,  1907,  the  proportion  of  malnourishment  cases 
varied  in  the  several  races. ^ 

TABLE  V 

Per  Cent  of  Fourteen  Hundred  New  York  School  Children 
Showing  Low  Nutrition,  1907 


Number 
Examined 

Per  Cent 

American 

300 
200 
300 
300 
300 

3.0 

German 

5.5 

Italian 

22.3 

Jewish 

11.3 

Various 

8.0 

Total 

1,400 

10.4 

The  high  figures  for  the  Italians,  which  are  over  seven 
times  that  for  the  American  child,  tells  its  own  story 
of  underfeeding  and  lack  of  bodily  vigor. 

Some  figures  from  East  Orange,  New  Jersey,  offer 
corroborative  evidence : 

Approximately  1,100  children  were  examined  at  the  be- 
ginning of  the  local  Children's  Year  campaign,  and  some 
interesting  facts  disclosed.  One  hundred  and  twenty-seven 
children,  or  11.6  per  cent  of  those  examined,  were  found  to 
be  sufficiently  under  weight  to  require  the  attention  of  a 
physician.  .  .  .  The  following  table  shows  the  per  cent  of 
children   under   weight   when   grouped   according   to   the 

1  Frank  A.  Manny,  "Nutrition  Study,"  Malnutrition  and  Race, 
sec.  xi,  chap.  G,  p.  3,  1916. 
4  37 


IMMIGRANT  HEALTH  AND  COMMUNITY 


nationality  of  the  mother,  and  presents  some  important 
figm-es : 

TABLE  VI 

Per  Cent  of  Children  Under  Weight  in  East  Orange,  New 
Jersey,  by  Nationality  of  Mother 


Nationality  of  Mothebs 


Sweden 

Germany 

Russia 

United  States,  white. . 

Italy 

England 

Ireland 

United  States,  colored 
All  other  countries .... 


Per  Cent 

OF  Children 

Under  Weight 


4.3 
7.7 
9.1 
10.0 
14.3 
15.9 
20.5 
22.6 
10.2 


These  figm-es  present  facts  which  correspond  to  previous 
general  impressions,  concerning  which  definite  information 
was  lacking.^ 

Interviews  carried  on  by  this  study,  with  doctors 
practicing  in  Italian  neighborhoods,  repeatedly  reveal 
the  great  prevalence  of  rickets  among  the  Italian 
children.  Dr.  Julius  Levy  writes  of  this  in  an  article 
on  the  pre-school  period.  Dr.  Antonio  Stella  of  New 
York  City  has  stated  that  70  to  80  per  cent  of  Ital- 
ian children  have  rickets.^  Were  material  compar- 
able to  that  on  the  Italians  available  for  other  races, 
differences  would  doubtless  appear,  which  would  bring 
out  the  necessity  for  special  provision  and  treatment. 

1  Health  News,  East  Orange,  vol.  ii,  July,  1918. 

2  Antonio  Stella,  M.D.,  "The  EfiFects  of  Urban  Congestion  on 
Italian  Women  and  Children,"  New  York  Medical  Record,  May  2, 
1908 


SICKNESS  AMONG  THE  FOREIGN  BORN 

A  great  service  can  be  rendered  by  gathering  data  on 
the  differences  of  racial  morbidity  tendencies. 


INSANITY   AMONG   THE   FOREIGN   BORN 

Data  on  the  occurrence  of  insanity  among  the  native 
and  foreign  born  are  more  extensive  than  on  that  of 
other  diseases.  A  careful  analysis  of  first  admissions 
to  hospitals  for  the  insane  was  made  by  the  New  York 
State  Hospital  Commission  in  1912.  It  was  found 
that  the  frequency  of  insanity  among  the  foreign  born 
was  2.19  times  as  great  as  among  the  native  through- 
out the  state. 

In  1918  again,  the  foreign  born  were  admitted  to 
hospitals  for  the  insane  considerably  in  excess  of  their 
proportion  in  the  general  population.  The  foreign 
born  comprise  30.4  per  cent  of  the  population  of  New 
York  State,  and  46.4  per  cent  of  all  admissions  to 
state  hospitals  were  foreign  born.  Figures  are  obtain- 
able on  both  the  race  distribution  of  all  insanity  and 
on  the  different  forms  of  insanity.^ 


TABLE  VII 
Comparison  of  Race  Distribution  in  Principal  Psychoses,  1918 


Psychoses 

Per  Cent  of  Total  First  Admissions  of  Each 
Rack 

Afri- 
can 

Ger- 
man 

He- 
brew 

Irish 

Italian 

Sla- 
vonic 

Mixed 

Senile    

5.2 
21.3 

5.2 
12.4 
29.6 

11.6 
17.3 
4.5 
12.2 
25.5 

5.8 
13.3 

0.2 
24.0 
35.2 

13.2 
9.9 

10.6 
9.8 

26.7 

6.2 
19.1 

2.3 
22.0 
26.6 

1.6 

6.7 

10.3 

14.0 

47.3 

10.2 

General  paralysis 

Alcoholic 

13.1 

4.5 

Manic-depressive 

Dementia  praecox 

12.4 
24.0 

^  Thirteenth  Annual  Report  of  New   York  State  Hospital  Corri' 
mission,  1918,  p.  322. 

39 


IMMIGRANT  HEALTH  AND  COMMUNITY 

From  an  analysis  of  this  table  it  appears  that  certain 
races  suffer  considerably  more  from  some  psychoses  than 
others.  The  Germans  and  Irish  show  the  highest  per  cents 
of  first  admissions,  due  to  senile  decay;  the  Italians,  Ger- 
mans, and  Hebrews,  from  general  paralysis.  For  alcoholic 
psychoses  the  Irish  and  Slavs  lead  all  the  rest,  a  fact  in 
entire  harmony  with  the  drinking  habits  of  these  races. 
Among  the  manic-depressives  the  Hebrews  and  Italians 
take  first  place.  Slavs  and  Hebrews  show  very  high  rates 
from  dementia  prsecox. 

These  figures,  bringing  out  the  marked  variation 
among  the  different  races,  have  no  place  in  this  study 
except  to  indicate  the  value  of  race  statistics.  They 
have  been  found  valuable  in  the  field  of  pyschiatry 
and  the  treatment  of  psychoses.  In  the  field  of  medi- 
cine similar  data  would  be  useful. 

RACIAL    DIFFERENCES    APPARENT 

In  conclusion,  the  scarcity  of  morbidity  data,  taking 
into  consideration  the  factor  of  race,  should  be  em- 
phasized. What  little  could  be  secured  is  not  suflfi- 
cient  to  establish  many  specific  points,  but  enough 
has  been  given  to  indicate  that  there  are  racial  dif- 
ferences in  liability  to  certain  diseases. 

The  general  morbidity  rate  seems  to  be  higher 
among  the  foreign  born  than  among  the  native  born. 
The  Italians  are  afflicted  with  pneumonia  and  other 
diseases  of  the  lungs  more  than  other  races,  and  suc- 
cumb more  readily  to  its  ravages.  This  is  especially 
true  of  the  children  of  the  pre-school  age.  Rickets, 
too,  is  a  menace  to  the  Italian  children.  Among  the 
Irish,  the  Italians,  Slavs,  and  Germans,  insanity  is  a 
thing  to  be  guarded  against.    How  much  these  are 

distinctly  racial  factors;   how  much  due  to  the  eco- 

40 


SICKNESS  AMONG  THE  FOREIGN  BORN 

nomic  conditions  under  which  our  immigrants  live — 
the  housing  and  overcrowding,  the  change  from  one 
diet  and  environment  to  another — is  uncertain.  The 
data  are  yet  inadequate  for  conclusions  as  to  causes. 
The  paucity  of  morbidity  statistics  relating  to  race 
tells  its  own  story  of  the  great  need  for  more  careful 
record-keeping  and  research  along  these  lines.  EjiowI- 
edge  of  what  diseases  attack  which  races,  and  why 
they  do  so,  is  vital  to  the  success  of  all  attempts  to 
improve  the  health  status  of  the  immigrant. 


Ill 


DEATH  RATES  OF  THE  FOREIGN  BORN 


In  interpreting  mortality  statistics  analyzed  for  racial 
factors,  there  are  certain  limitations  which  should  be 
enumerated.  Among  them  is  the  diflPerence  in  the  age 
distribution  of  the  native  population  and  of  the  foreign 
white  stock.  The  following  table,  taken  from  the 
United  States  Census  for  1910,  shows  this  point:* 

TABLE  VIII 

Age  Distribution  of  the  Population  of  the  United  ljjtates 
(Percentages),  1910 


Age  Period 

Native 
Parentage 

Foreign 
OR  Mixed 
Parentage 

Foreign  Bobn 

All  ages 

100.0 
13.2 
22.6 
19.7 
26.2 
13.6 
4.4 

100.0 
14.2 
24.1 
21.6 
27.6 
11.2 
1.4 

100.0 

Under  5  years 

.8 

5—14  years 

4.9 

15—24  years 

15.8 

25—44  years 

44.1 

45—64  years 

25.4 

65  years  and  over 

8.9 

The  native  population  has  a  much  larger  per  cent  of 
children  under  five,  babies  especially,  than  has  the 
foreign  white  stock.  The  latter,  as  a  natural  corollary, 
has  a  larger  proportion  of  persons  in  middle  life  and 
in  the  later  years. 

1  Thirteenth  Census  of  the  U.  S.,  1910,  vol.  i,  p.  298,  Table  XV. 

42 


DEATH  RATES  OF  THE  FOREIGN  BORN 

Since  infant  mortality  is  an  important  factor  in 
raising  the  general  death  rate  of  any  community,  the 
foreign  born,  who  include  practically  no  babies  and 
a  large  proportion  of  the  middle-aged  group,  whose 
death  rate  is  notably  low  in  most  populations,  might 
be  expected  to  have  a  lower  general  death  rate  than 
the  natives  of  native  parentage.  As  a  matter  of  fact, 
the  reverse  is  true.  The  data  collected  by  the  United 
States  Census  in  1900  definitely  established  this  con- 
clusion. Nineteen  hundred  was  the  only  year  that  a 
careful  report  of  mortality  data  by  race  was  printed 
by  the  Bureau  of  the  Census.^ 

TABLE  IX 

Death  Rates  Per  1,000  Populatiox,  by  Nativity,  for  Regis- 
tration Area,  1890  and  1900 


White  Only 

1S90 

1900 

Both  parents  native 

16.6 
16.6 
19.4 

17  3 

One  or  both  parents  foreign 

Foreig'i  born 

21.5 
19  4 

Another  factor  affecting  death  rates  is  the  sex  dis- 
tribution of  the  native  and  foreign  born.  In  1900 
there  were  102.8  native  white  males  to  every  100 
native  white  females,  while  there  were  117.4  foreign- 
bom  white  males  to  every  100  foreign-bom  white 
females.  On  account  of  the  higher  mortality  rate  of 
males>,  the  preponderance  of  this  sex  would  tend  to 
raise  the  general  death  rate  of  the  foreign  born. 

RACIAL  DIFFERENCES  IN  DEATH  RATES 

As  notable  as  the  differences  in  death  rates  between 
general  nativity  groups  are  those  between  races.    The 

*  Ttoelfih  Census  of  the  U.  S.,  1900,  Vital  Statistics,  vol.  iii,  p.  Ixx. 

43 


IMMIGRANT  HEALTH  AND  COMMUNITY 

following  table  shows  the  rates  for  persons  whose 
mothers  were  born  in  various  European  countries. 
The  difference  in  age  distribution,  particularly  the  large 
proportion  of  children  among  the  native  born,  explains 
the  fact  that  the  rate  for  persons  with  mothers  born 
in  the  United  States  is  higher  than  for  some  of  the 
other  countries. 

TABLE  X 

Death  Rate  for  White  Persons  Having  Mothers  Born  in 
Specified  Countries,  1900  ^ 


COUNTKT 

Death  Rate 

Ireland 

21.3 

Italy 

29.4 

France 

17.1 

Scotland 

15.8 

Germany , 

15.5 

Wales 

15  5 

United  States 

14.6 

Hungary  and  Bohemia 

12.9 

Scandinavia 

12.4 

Russia  and  Poland 

12.0 

It  is  difficult  to  account  for  the  wide  variation  evident 
in  this  table,  on  the  basis  of  the  facts  in  hand.  Occu- 
pational, social,  and  economic  influences  are  not  easy 
to  establish.  Sharp  changes  in  habits  of  living,  in 
food,  housing,  and  climate,  undoubtedly  leave  their 
traces  in  mortality  rates.  Their  relative  importance 
to  each  race  cannot  be  gauged  at  present  upon  a  sta- 
tistical basis.  There  are,  however,  a  number  of  care- 
ful studies  which  shed  more  light  upon  our  problem. 

In   1917  Dr.   William  H.   Guilfoy,   Registrar  of 
Records  of  New  York  City  Department  of  Health, 

^  Twelfth  Census  of  the  U.  S.,  1900,  Vital  Statistics,  vol.  iii,  p.  Ixxi. 

44 


DEATH  RATES  OF  THE  FOREIGN  BORN 


analyzed  the  statistics  of  the  city  with  special  refer- 
ence to  the  effect  of  nationality  on  mortality.^  The 
following  table  indicates  his  findings : 

TABLE  XI 

Death  Rate  per  1,000  Population  of  All  Persons  Five  Years 

OF  AGE  AND  OvER,  BY  NATIONALITY  AND  SeX,  IN  NeW  YoRK  CiTY 


Natioxality 


All. 


Irish . .  .  . 
German . 
English . 

Native. , 


Italian 

Austro-Hungarian . 
Russian 


INIale 


Female 


14.2 

10.8 

31.6 

25.5 

25.7 

18.5 

19.6 

14.7 

13.4 

9.8 

9.8 

8.5 

9.8 

7.0 

8.4 

6.6 

Although  this  table  and  the  1900  census  material 
quoted  earlier  are  not  strictly  comparable,  there  are 
certain  striking  points  of  resemblance  in  the  order  in 
which  w^e  find  the  nationalities. 

In  both  cases  the  Irish  lead  with  the  highest  death 
rate.  In  both  cases  the  Germans  are  found  to  have  a 
higher  rate  than  the  native  born,  and  the  Hungarians 
a  lower  rate.  At  the  bottom  of  both  lists  of  nationali- 
ties come  the  Russians,  with  the  lowest  rate  of  all. 
The  majority  in  this  group  are  Jews.  The  Italian  is 
the  large  nativity  group  which  shows  a  striking  dis- 
crepancy in  the  two  tables.     In  the  U.  S.  Census 

1  William  H.  Guilfoy,  M.D.,  New  York  City  Department  of 
Health,  "Influence  of  Nationality  upon  the  Mortality  of  a  Com- 
munity," Monograph  Series  No.  18,  November,  1917,  pp.  20-24. 

45 


IMMIGRANT  HEALTH  AND  COMMUNITY 

table  its  death  rate  of  20.4  is  next  to  the  highest.  In 
the  New  York  City  table  the  death  rate  for  Italian  males 
is  9.8,  and  females  8.5,  figures  less  than  half  the  earlier 
death  rate.  Further  inquiry  may  illumine  these  points. 

DIAGRAM  3. VARIATION  BY  NATIONALITY   IN  DEATH  RATES 

PER   1,000,  OF  ALL  MALES  FIVE  YEARS  OF  AGE  AND  OVER 
IN  NEW  YORK   CITY,    1917 


ALL  |14 


IRISH 


GERMAN  26 


ENGLISH  |20 


|native 

1 

JlTALIAN                           |lO 

. 

|AUSTRO-HUNGARIAt«4ld 

Irussian         la 

1,3 


Interesting  material  is  furnished  by  Dublin  in  his 
study  of  death  rates  of  persons  in  the  older  age  periods, 
in  which  he  contrasts  the  different  races  ^  (Table  XII). 
Here  again,  a  higher  mortality  rate  than  that  of  the 
native  born  is  clearly  shown  for  every  race  in  the 
younger  age  group.  In  addition,  the  nationalities 
arranged  according  to  highest  male  mortality  rates 
in  the  first  age  period  are  in  virtually  the  same  order 
as  in  Tables  X  and  XI.  The  Irish  exceed  the  other 
nationalities  by  a  wide  margin,  and  Russians  (largely 
Jews)  are  found  second  from  the  bottom  of  the  list. 
The  Italians  show  the  lowest  mortality  rate  in  three 
of  the  four  columns.    This  low  rate  corresponds  with 

^ Louis  I.  Dublin,  "Increasing  Mortality  after  Age  Forty-five," 
Quarterly  Publication  of  the  American  Statistical  Associationf 
March,  1917,  pp.  514-516. 

46 


DEATH  RATES  OF  THE  FOREIGN  BORN 

TABLE  XII 

Death  Rates  per  1,000  in  Principal  NATmTY  Classes  of  New 
York  State  Population,  1910,  by  Age  Period  and  Sex 


Nativitt 


Native  born  of  native  parentage. ... 
Native  born  of  foreign  or  mixed  par 

entage 

Foreign  born 

Ireland 

Germany 

England,  Scotland,  Wales 

Austria-Hungary 

Russia 

Italy 


45-64  Years 


Male 


18,8 

28.2 
28.0 

46.3 
27.7 
24.6 
21.0 
20.1 
19.3 


Female 


14.3 

20.0 
23.4 

40.7 
18.4 
21.0 
18.2 
16.0 
17.9 


65-84  Yeae8 


Male 


77.3 

89.9 
90.4 

101.6 
90.4 
86.6 

77.5 
78.4 
64.6 


Female 


68.2 

73.9 

87.7 

107.4 
83.1 
79.9 
63.9 
69.8 
63.8 


the  figure  for  the  Itahans  in  New  York  City,  and  con- 
trasts with  the  figure  for  the  country. 

The  nationahty  figure  which  shows  a  decided  shift 
in  its  position  in  the  three  tables  is  the  ItaHan.  The 
figures  could  not  be  expected  to  coincide  because  of 
the  variation  in  the  bases;  but  the  similarity  in  the 
order  of  the  other  nationalities  is  notable.  Special 
causes  no  doubt  operate  in  connection  with  the  Ital- 
ians, about  which  no  figures  are  available  at  present. 

Dr.  William  H.  Davis,  now  with  the  Bureau  of  the 
Census  in  Washington,  made  in  1916  an  illuminating 
analysis  of  mortality  data  for  the  city  of  Boston.^  His 
conclusions  are  similar  to  those  of  Guilf  oy  and  Dublin : 

These  rates,  based  upon  the  1910  census  and  the  deaths 
of  1910,  present  a  picture  of  the  iafluence  of  the  foreign 
population  almost  identical  with  the  picture  based  upon  the 

^  William  H.  Davis,  M.D.,  The  Relation  of  the  Foreign  Population 
to  the  Mortality  Rates  of  Boston,  1916,  pp.  5-6. 

47 


IMMIGRANT  HEALTH  AND  COMMUNITY 

rates  of  1900.  Therefore,  it  is  evident  that  these  differences 
in  the  rates  of  various  nationalities  are  not  due  to  chance, 
but  to  actual  differences  in  the  peoples  themselves,  or  in 
their  occupations,  or  in  their  manner  of  living. 

Some  of  the  factors  causing  the  differences  or  affecting 
the  order  of  national  mortality  rates  may  be  brought 
to  light  by  considering  the  causes  of  deaths.  Material 
is  available  showing  the  nationalities  affected  by  the 
degenerative  diseases — ^pneumonia  and  the  acute  in- 
fections, and  tuberculosis. 


DEATHS  FROM  DEGENERATIVE  DISEASES 

In  the  1900  census,  death  rates  from  the  chief  degen- 
erative diseases  are  classified  for  the  different 
nationalities.^ 

TABLE  XIII 

Death  Rate  from  Certain  Diseases  Among  Whites,  Classified 
According  to  Birthplace  of  Mother.  Registration 
Area,  1900 


Deaths  per  100,000  Popul-^tion 

Birthplace  op  Mother 

Digestive 
System  ^ 

Bright's 
Disease 

Circula- 
tory 
System  2 

Alcohol- 
ism 

Rate 

Rank 

Rate 

Rank 

Rate 

Rank 

Rate 

Rank 

United  States 

79.7 

116.6 

100.4 

99.1 

72.1 

68.2 

89.3 

75.3 

132.8 

79.7 

61.6 

94.1 

7 
2 
3 

4 

10 

11 

6 

9 

1 

7 

12 

5 

55.5 
134.8 
86.8 
85.1 
35.1 
38.4 
87.5 
36.6 
117.8 
39.3 
28.7 
49.6 

6 

1 
4 
5 

11 
8 
3 

10 
2 
9 

12 
7 

126.8 

205.5 

144.9 

165.7 

90.4 

68.8 

171.8 

76.4 

176.7 

66.4 

55.4 

102.7 

6 
1 

5 

4 

8 

10 

3 

9 

2 

11 

12 

7 

2.4 
17.7 
6.1 
8.3 
3.7 
5.5 
9.7 
0.7 
7.0 
3.9 
1.7 
4.2 

10 

Ireland 

1 

Germany 

5 

England  and  Wales 

Canada 

3 
9 

Scandinavia 

6 

Scotland 

2 

Italy 

12 

France 

4 

Hungary  and  Bohemia. . . 

Russia  and  Poland 

Other  foreign 

8 

11 

7 

1  Stomach,  liver,  and  peritonitis. 

2  Heart  disease  and  dropsy,  angina  pectoris. 


1  Twelfth  Census  of  the   U.  S.,  1900,  Vital  Statistics,  vol.  iii, 
p.  Ixxviii. 

48 


DEATH  RATES  OF  THE  FOREIGN  BORN 

The  outstanding  feature  of  this  table  is  the  high  death 
rate  that  the  Irish  show  from  all  four  causes.  Their 
death  rate  of  17.7  from  alcoholism  is  the  most  con- 
spicuous fact  of  the  table.  This  figure  is  almost 
double  the  next  nearest  in  rank  and  partially  accounts, 
no  doubt,  for  the  high  rank  of  the  Irish  in  the  other 
causes  of  death,  which  in  every  instance  obtains. 
Disregarding  the  figure  for  the  French  because  so 
small  a  unit  of  population  was  included,  we  find  the 
Germans,  English,  and  Scotch  following  the  Irish 
closely  in  a  high  mortality  rate.  At  the  other  end  of 
the  scale  are  the  Russians  and  Poles,  who  have  the 
lowest  rate  of  all  nations  from  all  causes  except  alco- 
hoHsm,  from  which  they  have  next  to  the  lowest  rate. 
It  must  be  borne  in  mind  that  a  large  proportion  of 
the  Russians,  and  many  of  the  Poles,  are  not 
Slavs,  but  Jews. 

The  ranks  of  the  Italians  remain  comparatively 
low  in  the  four  columns,  proving  to  be  lower  than  the 
native  born  in  every  case.  From  these  figures  it  is 
possible  to  prognosticate  in  a  general  way  the  causes 
of  death  in  a  community  whose  racial  elements  are 
dominantly  any  of  those  included  in  this  table.  This 
information  again  emphasizes  the  need  of  considering 
racial  factors  in  practical  attempts  to  lower  mortality 
rates. 

Both  Dublin  and  Guilfoy  come  to  much  the  same 
conclusions  in  their  study  of  the  influence  of  nation- 
ality upon  mortality.  Guilfoy  finds  in  New  York 
City  that:^ 

1  William  H.  Guilfoy,  M.D.,  "The  Influence  of  Nationality 
upon  the  Mortality  of  a  Community,"  New  York  City  Department 
of  Health,  Monograph  Series  No.  18,  November,  1917,  pp.  20-21.  See 

49 


IMMIGRANT  HEALTH  AND  COMMUNITY 

The  males  of  the  four  countries — United  States,  Ireland, 
Germany,  and  England — show  excessive  mortality  from 
these  causes  [alcoholism  and  cirrhosis  of  the  liver].  The 
deaths  among  the  Italians,  Russians,  and  Austro-Hungari- 
ans  are  so  few  as  to  be  negligible.  .  .  .  Considering  the  de- 
generative diseases,  we  find  that  the  Irish  males  lead  the 
mortalities  with  a  rate  of  1,010  (per  100,000  population), 
followed  by  the  German  males  with  a  rate  of  965,  and  an 
English  male  rate  of  635,  all  considerably  above  the  rate 
for  all  males.  Irish  females,  German  females,  and  English 
females  also  show  higher  mortalities  than  that  of  all  females. 

In  conclusion  it  may  be  said  that  the  foreign  white 
stock  suffer  from  a  higher  rate  of  premature  deaths 
from  the  degenerative  diseases  than  do  the  native 
born,  and  certain  races,  notably  the  Irish  and  Ger- 
mans, show  mortality  rates  from  these  diseases  which 
far  exceed  those  of  any  other  group. 

PNEUMONIA   AND   THE  ACUTE   INFECTIONS 

Table  IV  in  Chapter  II,  presented  cases  of  pneumonia 
and  other  respiratory  diseases  attended  by  Henry 
Street  nurses,  as  well  as  the  number  of  deaths  from 
these  causes.  There  was  a  high  per  cent  of  deaths  for 
Italians  in  all  age  groups,  being  8.9  per  cent,  as  con- 
trasted with  2.6  per  cent  for  the  Hebrews.  Especially 
notable  is  the  high  ratio  (17.7)  for  Italian  children 
under  one  year  of  age.  The  following  table  con- 
clusively corroborates  the  evidence  of  their  suscepti- 
bility to  respiratory  diseases  and  to  acute  infections 
as  well: 


also  Louis  I.  Dublin,  "Increasing  Mortality  after  Age  Forty- 
five,"  Quarterly  Publication  of  American  Statistical  Association, 
March,  1917,  pp.  514-518,  523. 

50 


DEATH  RATES  OF  THE  FOREIGN  BORN 


TABLE  XIV 
Death  Rate  of  Whites  fbom  Certain  Respiratory  Diseases 
AND   Acute   Infections,    Classified    by    Birthpl.a.ces   of 
Mothers,  per  100,000  Population  of  Registration  Area, 
1900  1 


Causes 

OF   D 

eath 

Respiratory 

D 

ISE.^SE3 

Acute  i 

vfections 

Birthplace  of 

1 

"3 
a 

MOTHEB 

>> 

o 

o 

.2 
'.5 

> 

1^ 

.2 

'(4 

.5  c 

I-    3 

tp 

? 

o 

u    « 

a 

o 

\3 

o 

-^ 

ja 

^  t-i 

a  -. 

u 

c"5 

o 

a 
o 

e3 

e3 

-    3 

^'^ 

a 

% 

CO 

Q 

Qg 

^6 

6^X 

United  States — 

211.6 

142.8 

35.7 

11.9 

11.0 

30.9 

40.7 

14.0 

8.6 

Italy 

705.5 
365.3 

479.8 
257.5 

175.6 
65.1 

62.6 
10.4 

15.5 
9.6 

48. 7 
26.9 

67.4 
32.8 

20.9 
10.9 

11.2 

Ireland 

5.7 

Hungary  and  Bo- 

hemia  

272.5 

206.6 

33.5 

8.8 

13.8 

37.4 

49.2 

8.4 

4.9 

Russia  and  Po- 

land   

268.5 
245.7 

197.6 
161.1 

40.8 
47.0 

13.5 
8.9 

18.4 
7.6 

39.6 
29.0 

49.7 
37.7 

11.7 
6.9 

7.6 

Germany 

3.9 

England   and 

Wales 

228.7 

156.9 

36.7 

7.9 

8.3 

19.7 

25.4 

10.1 

5.2 

Scotland 

221.1 

154.1 

38.2 

5.8 

9.4 

19.5 

23.1 

6.5 

7.2 

Canada 

209.4 
209.8 

136.2 
148.3 

40.3 
33.0 

17.3 

13.4 

11.5 
13.6 

30.0 
35.6 

40.9 
44.6 

16.0 
16.1 

9.4 

Scandinavia 

8.4 

France 

208.  6 
327.5 

145.7 
226 . 5 

3S.9 
57.9 

2.0 
23.6 

3.0 
12.0 

10.0 
31.7 

11.0 
44.1 

6.0 
19.5 

5.0 

Other  foreign. . .  . 

9.9 

1  Tubercvdosis  excluded. 

The  rates  for  the  Italians  from  every  cause  of  death 
are  double  those  for  almost  every  other  race. 

Guilfoy  says,  in  his  report  on  mortality  in  New 
York  City,  that  the  death  rate  from  respiratory  dis- 
eases among  infants  of  Italian  mothers  is  from  two  to 
three  and  a  half  times  that  among  children  of  mothers 
of  all  other  nationalities.  Dublin  also  was  much 
struck  by  the  high  general  death  rate  of  the  Italians 
in  New  York  State,  and  sought  to  discover  the  causes. 
He  found  that  in  practically  every  age  period  the 

1  Twelfth  Census  of  the  U.  S.,  1900,  Vital  Statistics,  vol.  iii, 
pp.  Ixvii,  Ixxxiii. 

51 


IMMIGRANT  HEALTH  AND  COMMUNITY 

pneumonia  death  rate  for  Italians  is  about  twice  that 
of  native  Americans — sometimes  the  proportion  is 
even  greater.  The  differences  are  especially  marked 
among  women. 

Like  Abou  Ben  Adhem,  Italy's  name  leads  all  the 
rest  in  this  table.  Since  the  fatal  termination  of  many 
of  the  acute  infections  is  due  to  some  form  of  pneu- 
monia, the  high  rates  from  these  diseases  may  result 
from  inaccuracy  in  reporting  the  immediate  cause  of 
death.  In  so  far  as  this  is  the  case,  the  rate  from 
pneumonia  is  not  nearly  so  high  for  the  Italians  as  it 
should  be. 

Dr.  Antonio  Stella,  in  a  block  study  of  mortality 
among  the  Italians  in  New  York  City  in  1908,  found 
the  same  conditions  there. ^  While  the  death  rate  from 
the  acute  respiratory  diseases  for  the  city  was  12.7 
per  1,000,  for  the  Italians  in  the  ten  blocks  studied  it 
ranged  from  17.9  to  49.0,  and  was  usually  over  30.0. 
From  diphtheria,  the  city  rate  was  2.8,  and  the  Italian 
3.2  to  8.9,  usually  over  4.0.  The  broncho-pneumonia 
death  rate  for  Italian  children  under  five  was  two  and 
one  half  times  the  American  rate.  The  mortality 
from  measles  was  five  times  the  city  death  rate  from 
that  disease. 

There  are  no  such  outstanding  figures  for  any  other 
nationality.  The  Irish  rank  second  to  the  Italians  in 
all  the  respiratory  diseases,  but  they  hold  a  low  rank 
in  the  acute  infections.  Contrary  to  expectation  based 
on  the  general  mortality  tables  previously  quoted,  the 
Russians  and  Poles  come  near  the  first  rank  in  deaths 


1  Antonio  Stella,  M.D.,  "The  Effects  of  Urban  Congestion  on 
Italian  Women  and  Children,"  New  York  Medical  Record^  May  2, 
1008,  pp.  722-732. 

52 


DEATH  RATES  OF  THE  FOREIGN  BORN 

from  several  of  the  causes  listed.  They  rank  first  in 
deaths  from  scarlet  fever  and  second  in  deaths  from 
diphtheria  and  diphtheria  and  croup. 

No  other  nationality  has  a  consistent  or  striking 
rank  according  to  cause  of  death.  Even  for  the  group 
whose  mothers  were  born  in  the  United  States  there 
are  higher  death  rates  from  the  acute  infections  than 
for  a  number  of  the  other  nationalities.  With  respect 
to  the  hazards  of  these  diseases,  one  may  parody  the 
inquiry,  "  Does  it  pay  to  be  healthy,"  by  asking,  "Does 
it  pay  to  be  native  born.^" 

The  fact  that  pneumonia,  respiratory  diseases — ex- 
cept tuberculosis — and  the  acute  infections  seem  to 
play  so  fatal  a  part  in  the  lives  of  the  Italians  in  the 
United  States,  provides  a  practical  point  of  attack 
for  those  who  would  lower  general  death  rates  among 
these  foreign-born  Americans  and  their  children. 


TUBERCULOSIS 

The  Irish  are  conspicuous  in  tuberculosis  statistics  by 
reason  of  their  exceedingly  high  death  rate  from  this  dis- 
ease (Table  XV) .  Russia  and  Poland  again  stand  at  the 
foot  of  the  list,  having  a  death  rate  from  consumption 
more  than  a  third  less  than  that  of  the  United  States, 
which  in  turn  is  the  lowest  of  any  nationality  but  one. 
This  low  mortality,  if  not  immunity,  from  the  great 
scourge  of  tuberculosis,  is  a  fact  to  be  remembered 
in  health  work  with  the  Jews.  It  will  be  seen  that 
the  death  rate  among  the  Irish  is  more  than  three 
times  that  of  those  whose  mothers  were  born  in  the 
United  States,  and  almost  twice  that  of  any  other  race. 

n  53 


IMMIGRANT  HEALTH  AND  COMMUNITY 


TABLE  XV 

Death  Rate  op  Whites  from  Consumption,  per  100,000 
Population  of  Registration  Area,  1900  * 


Birthplace  of  Motheb 


United  States 

Ireland 

France 

Scotland 

Germany 

Canada 

England  and  Wales . . . 

Italy 

Hungary  and  Bohemia 
Russia  and  Poland .... 
Other  foreign 


Cause  op  Death 


Consumption 


112.8 

339.6 
184.7 
172.5 
167.0 
143.1 
135.1 
113.6 
107.7 
71.8 
153.8 


Guilfoy  speaks  of  the  fact  of  high  mortality  of  the 
Irish  in  his  article  on  the  influence  of  nationality  on 
mortality  in  New  York  City.^ 

The  death  rate  at  all  ages  .  .  .  from  pulmonary  tuber- 
culosis is  noteworthy  by  reason  of  the  excessively  high 
rate  among  the  Irish  males;  701  out  of  every  100,000  died 
as  compared  with  333  native  males  .  .  . 

Dr.  Donald  B.  Armstrong,  in  the  course  of  the 
tuberculosis  experiment  conducted  during  the  past 
three  years  in  Framingham,  Massachusetts,  found  the 
same  excessive  death  rate  for  this  race.^    Analysis  of 

1  Twelfth  Census  of  the  U.  /S.»  1900,  Vital  Statistics,  vol.  iii, 
p.  Ixxxviii. 

2  William  H.  Guilfoy.  M.D..  "The  Influence  of  Nationality 
upon  the  Mortality  of  a  Community,"  New  York  City  Departmeni 
of  Health,  Monograph  Series  No.  18,  November,  1917,  pp.  20-21. 

8  "Vital  Statistics,"  Sanitary  Series  No.  1,  Framingham  Mono- 
graph No.  3t  Appendix  A,  Tables  IV  and  XIII. 

54 


DEATH  RATES  OF  THE  FOREIGN  BORN 

his  data  shows  that  although  the  Irish  stock  repre- 
sents only  16.5  per  cent  of  the  population,  they  sup- 
plied 28  per  cent  of  the  deaths  from  tuberculosis  for 
1907-16.  He  also  points  to  the  low  death  rate  of  the 
Russians  (Jews)  in  Framingham. 

In  Table  XV  the  death  rate  from  tuberculosis  of 
the  Italians  is  113.6.  This  figure  is  about  that  of  the 
native  born,  and  is  fourth  lowest  in  the  scale  for  all 
nationalities.  The  low  death  rate  from  tuberculosis 
of  the  Italians  is  brought  out  in  other  studies.  In 
the  Framingham  study  mentioned  above,  Italians 
represent  7.7  per  cent  of  the  residents,  and  only  5  per 
cent  of  the  deaths  from  tuberculosis. 

This  fact  seems  particularly  remarkable  in  view  of 
the  extremely  high  Italian  death  rate  from  diseases  of 
the  respiratory  system,  noted  in  Table  XI,  Chapter 
II,  and  Table  XIV  of  this  chapter.  One  supposition 
is  that  the  Italian  goes  back  to  Italy  as  soon  as  he 
learns  that  he  has  tuberculosis.  Many  doctors  inter- 
viewed by  the  study  testified  to  this  fact.  Stella 
states  that  of  81,412  Italians  returning  to  Italy  in 
1906,  about  450,  or  5.61  per  1,000,  were  advanced 
cases  of  this  disease.^  When  the  Italian,  particularly 
the  southern  Italian,  falls  ill  with  tuberculosis,  mem- 
ories of  the  home  people  and  of  sunny  hills  seem  to 
pull  him  back  with  irresistible  force  to  die  in  Italy. 
Such  considerations,  impossible  of  statistical  classifi- 
cation, may  account  for  many  of  the  figures.  In  sum- 
marizing the  scattered  data  presented  in  this  chapter 


*  Antonio  Stella,  M.D.,  "The  Effects  of  Urban  Congestion  on 
Italian  Women  and  Children,"  New  York  Medical  Record,  May  2, 
1908. 

55 


IMMIGRANT  HEALTH  AND  COMMUNITY 

we  shall  see  how  they  relate  to  the  principal  racial 
groups. 

HIGH   MORTALITY  OF  THE  IRISH 

From  data  in  the  earlier  part  of  the  chapter  the  high 
death  rate  of  the  Irish  was  apparent.  In  the  census 
figures  of  1900,  and  in  later  figures  for  both  New  York 
State  and  city,  this  race  stands  consistently  first 
among  nationalities  ranged  in  order  of  mortality  rates. 
This  rank  is  the  more  striking  because  the  rates  are 
about  twice  as  large  as  comparable  figures  in  Ireland. 
What  elusive  influences  play  upon  this  race  as  it  is 
transplanted  to  another  land,  it  is  difficult  to  discover. 
A  closer  picture  of  conditions  can  be  obtained  from 
the  figures  on  causes  of  death. 

Alcoholism,  as  a  cause  of  death  among  the  Irish,  is 
the  outstanding  feature  of  Table  XIII.  This  race 
also  takes  primary  rank  in  deaths  from  other  diseases, 
such  as  Bright's  disease,  those  of  the  digestive  system, 
the  circulatory  and  respiratory  systems,  as  shown  in 
Tables  XIII  and  XIV,  Ireland  heads  the  death  rates 
from  consumption,  showing  a  rate  almost  twice  that 
of  the  next  nearest  figure,  as  seen  in  Table  XV.  In 
Doctor  Davis's  study  of  mortality  in  Boston,  referred 
to  above,  the  same  excessive  mortality  of  the  Irish 
was  noted. 

Whether  there  is  a  relation  between  the  high  figure 
on  alcoholism  and  susceptibility  to  these  diseases  is 
problematical.  At  least,  their  coincidence  is  sugges- 
tive. Since  the  Eighteenth  Amendment  to  the  United 
States  Constitution  has  been  passed,  another  decade 
may  throw  more  light  on  these  conditions.  Less  out- 
standing, but  equally  to  be  noted,  is  the  comparatively 

56 


DEATH  RATES  OF  THE  FOREIGN  BORN 

low  rank  (Table  XIV)  the  Irish  hold  in  deaths  from 
the  acute  infections.  Here  they  consistently  show  a 
lower  rate  than  the  native  born.  This,  too,  is  a  fact 
to  be  held  in  mind  in  considering  racial  differences. 


LOW  MORTALITY  OF  RUSSIANS 

In  contrast  to  the  mortality  rate  of  the  Irish  we  find 
that  of  the  Russians  at  the  bottom  of  the  list.  They 
rank  low  in  the  census  data  for  1900,  when  they  are 
classified  "wHith  the  Poles;  they  are  found  at  the  bot- 
tom of  the  table  for  New  York  City,  and  rank  among 
the  lowest  in  the  table  for  New  York  State.  The 
Russians  include  a  large  proportion  of  Jews  (about 
half  of  all  the  Russians  in  the  United  States  in  1910 
were  Jews,  and  in  New  York  City  the  proportion  is 
much  larger),  and  Jews  generally  show  a  lower  mor- 
tality rate  than  any  nationality  among  which  they 
live.  WTiatever  may  be  the  explanation  of  this  fact, 
it  accounts  for  the  figures  here  presented. 

In  the  tables  showing  causes  of  death  the  Rus- 
sians do  not  maintain  a  fixed  relation  to  the  other 
nationalities.  They  are  found  at  the  foot  of  the  list 
for  the  so-called  degenerative  diseases,  showing  in 
each  case  a  lower  rate  than  the  native  born  (Table 
XIII).  For  the  respiratory  diseases  they  rank  fifth 
in  each  case.  To  the  acute  infections  they  show  a 
much  higher  susceptibility. 

It  is  hard  to  trace  this  high  mortality  to  any  meas- 
urable factor.  Such  explanations  as  congested  and 
unsanitary  living  conditions  are  at  best  mere  surmises. 
The  strikingly  low  death  rate  from  tuberculosis, 
which  is  about  a  third  less  for  these  people  than  for 

51 


IMMIGRANT  HEALTH  AND  COMMUNITY 

those  of  native  mothers,  is  a  fact  of  no  slight  import. 
Exposure  to  urban  conditions  for  many  generations, 
and  consequent  elimination  of  stocks  unable  to  resist 
the  prevalent  urban  infections,  is  a  probable  factor  in 
this  low  rate  among  the  Jews. 

ITALIAN  DEATH  RATE  NOT   UNIFORM 

The  Italian  death  rate  varies  more  than  the  Russian. 
For  the  degenerative  diseases  it  is  lower  than  that  of 
the  native  born.  In  the  consumption  table  we  find 
the  Italian  death  rate  about  equal  to  the  native,  a 
figure  which  is  low  compared  to  the  other  races.  But 
for  the  other  respiratory  diseases  and  the  acute  in- 
fections, the  Italians  have  the  highest  rate,  with  one 
exception,  of  any  racial  group,  varying  from  over  five 
times  that  of  the  native  group  to  slightly  less  than  it. 
This  range  in  mortality  rate,  from  less  than  the 
native  to  over  five  times  it,  is  analogous  to  what  is 
commonly  considered  the  volatility  of  the  Italian 
temperament.  Perhaps  the  return  of  the  Italian  to 
Italy,  when  he  knows  he  has  tuberculosis,  fully  ex- 
plains the  low  figure  for  that  disease.  The  causes 
affecting  death  rates,  with  this  race  as  with  all,  must 
be  widely  sought  in  general  attitudes  and  aptitudes, 
as  well  as  in  physical  conditions  of  living  and  working. 
The  present  brief  outline  of  available  data  has  served 
its  purpose  if  it  has  indicated  racial  variations  and  the 
possibility  of  further  inquiries. 

INFANT   MORTALITY 

The  final  group  of  mortality  statistics  to  be  discussed 

here  is  that  relating  to  infants.    The  first  question  to 

5S 


/ 


DEATH  RATES  OF  THE  FOREIGN  BORN 

be  answered  is  whether  or  not  babies  of  the  foreign 
born  show  a  higher  death  rate  than  those  of  the 
natives. 

According  to  the  1900  census  the  children  born  of 
native  parents  had  135.3  deaths  to  every  1,000  births; 
those  born  of  parents,  either  one  or  both  of  whom 
were  foreign  born,  had  149.2;  those  born  abroad  had 
141.1.^  The  figure  for  the  foreign-born  babies  need 
not  be  considered,  as  the  number  of  children  under 
one  year  brought  to  the  United  States  and  dying  here 
is  small,  only  about  400  for  the  whole  registration 
area  as  against  37,000  deaths  among  native-born 
babies  of  foreign  parents.  The  other  two  figures  are 
comparable,  and  indicate  clearly  that  infants  of 
foreign  parentage  suffer  from  a  higher  mortality  rate 
than  those  of  native  parentage. 

In  1919,  Eastman,  of  the  New  York  State  Depart- 
ment of  Health,  made  an  analysis  of  the  infant  mor- 
tality statistics  for  that  state,  in  order  to  see  whether 
or  not  there  was  any  connection  between  race  and 
infant  mortality  rates.  The  report  is  full  of  tables, 
with  careful  interpretations  by  the  author,  which  are 
too  long  for  reproduction  here.  Certain  of  Eastman's 
observations  and  conclusions  will  be  quoted.^ 

It  appears  [he  saysl  that  the  mortality  of  babies  under 
one  month  old  is  higher  among  those  born  to  native  mothers 
than  among  children  born  of  women  of  foreign  nativity. 
Although  the  mortality  of  children  less  than  one  year  of 
age  born  of  native  women  was  only  87  per  1,000  births. 


*  Twelfth  Census  of  the  U.  S.,  1900,  Vital  Statistics,  vol.  iii,  pp. 
Ixxxviii  and  286. 

*  P.  R.  Eastman,  The  Relation  of  Parental  Nativity  to  the  Infant 
Mortality  of  New  York  State,  American  Medical  Association,  1919. 

59 


IMMIGRANT  HEALTH  AND  COMMUNITY 

compared  with  108.4  for  children  of  foreign-born  mothers, 
the  rate  under  one  month  for  the  former  was  47.4  as  against 
45.2  for  the  latter.  Attention  is  also  directed  to  the  fact 
that  the  infant  mortality  of  the  children  of  native  mothers 
more  than  one  month  of  age  and  less  than  one  year  old,  was 
only  39.6  contrasted  with  63.2  for  babies  born  to  foreign 
mothers.  .  .  . 

The  infant  mortality  from  communicable  diseases  was 
almost  75  per  cent  greater  among  children  of  foreign  mothers 
than  among  the  babies  of  native  mothers;  from  respiratory 
diseases  it  was  more  than  100  per  cent  greater,  and  from 
gastro-intestinal  diseases  the  excess  was  about  78  per  cent; 
but  the  rate  from  prenatal  and  other  causes  peculiar  to 
early  childhood  was  higher  among  the  native  element  by 
more  than  20  per  cent. 

There  is  further  analysis  of  the  New  York  State 
figures,  but  the  main  fact  is  this,  there  is  a  measur- 
able difference  in  resistance  between  children  of 
native  and  of  foreign  parents  for  both  age  periods 
under  one  month  and  between  one  month  and  one 
year.  Examination  of  these  differences  leads  to  the 
conclusion  "that  the  chief  causes  of  infant  mortality 
among  the  native  population  originate  for  the  most 
part  in  adverse  prenatal  conditions,  but  that  among 
the  foreign  element  the  most  frequent  causes  of 
deaths  are  communicable,  respiratory,  and  gastro- 
intestinal diseases." 

Turning  again  to  Guilfoy's  figures  for  New  York 
City,  we  find  the  same  wide  variation  among  the  races 
that  appeared  in  his  total  mortality  data.  The  fol- 
lowing table  sums  up  his  findings  } 


1  William  H.  Guilfoy,  M.D.,  "Influence  of  Nationality  upon 
Mortality  of  a  Community,"  New  York  City  Department  of  Health, 
Monograph  Series  No.  18,  November,  1917,  p.  24. 

60 


DEATH  RATES  OF  THE  FOREIGN  BORN 

TABLE  XVI 

Mortality  of  Children  under  Five  Years  of  Age  and  under 
One  Year,  in  New  York  City  in  1915,  Classified  by  Birth- 
place of  Mother 


Deaths  per  1,000 

BiKTHPLACE    OF   MOTHER 

Under  Five  Years 
(Rate) 

Under  One  Year 
(Rate) 

Italy 

42.5 
40.5 

40.0 

36.8 
32.3 
26.3 
24.9 

103 

Eno'land 

138 

United  States 

106 

Ireland 

119 

Germany 

115 

Austro-Hungary 

Russia  ^ 

79.8 
77.9 

*  Figure  includes  Polish. 

Here  the  rank  of  Italians  and  the  low  rank  of  Rus- 
sians, with  their  preponderant  numbers  of  Jews,  cor- 
responds with  the  total  death-rate  tables  quoted 
earlier  in  the  chapter. 

The  most  intensive  studies  in  the  field  of  infant 
mortality,  from  a  social  rather  than  a  medical  point 
of  view,  have  been  made  by  the  Children's  Bureau. 
Racial  differences  are  apparent  in  these,  as  the 
briefest  reference  to  the  findings  of  the  studies  made 
in  Manchester,  Johnstown,  and  Brockton  will  indi- 
cate. The  following  table  compares  the  death  rate 
for  the  children  under  one  year  of  age,  of  native 
and  foreign-born  mothers,  in  these  three  places. 
We  fijid  here  wide  variation  among  the  three  towns, 
especially  for  the  rate  of  children  with  foreign-bom 
mothers,  which  is  twice  as  high  in  Manchester  as  in 
Brockton.     The  range  is  not  so  great  in  the  three 

towns  between  those  of  native  mothers.     The  rates 
.     .  61 


IMMIGRANT  HEALTH  AND  COMMUNITY 

of  the  different  cities  are  not  exactly  comparable,  since 
the  surveys  were  made  in  three  different  years. 

TABLE  XVII 

Mortality  Rates  op  Infants  under  One  Year  Classified  by 
Nationality  of  Mothers  in  Three  Cities,  Studied  by 
Children's  Bureau  * 


City 

Rate  per  1,000 

Native 

Foreign  Born 

Manchester,  New  Hampshire .... 

Johnstown,  Pennsylvania 

Brockton,  Massachusetts 

128.1 
104.3 
101.5 

183.5 

171.3 

92.0 

It  is  common  to  find  the  death  rates  of  the  native 
born  lower  than  those  of  the  foreign  born.  This  is 
true  in  two  of  the  places  listed,  but  not  in  Brockton. 
At  the  same  time,  stillbirths  were  twice  as  numerous 
among  the  foreign  born  as  among  the  native  born. 
More  detailed  analysis  would  be  needed  fully  to  ex- 
plain this  variation.  Brockton  is  a  prosperous  shoe- 
manufacturing  town  where  almost  half  the  foreign 
born  come  from  English-speaking  countries.  This 
might  explain  the  lower  foreign-born  rate. 

The  high  figure  for  Manchester  is  largely  due  to 
the  high  death  rate  (224.7)  of  French-Canadian 
mothers.  The  single  race  that  brings  up  the  figures 
for  Johnstown  is  that  for  the  Serbo-Croatian  mothers, 
who  have  a  rate  of  263.9.  In  the  case  of  Manchester 
the  French-Canadians  are  "generally  thrifty,  self- 
respecting  people,  ambitious  to  own  their  homes  and 
to  accumulate  property. . . .  On  the  whole,  they  occupy 

1  Beatrice  Sheets  Duncan  and  Emma  Duke,  "Infant  Mortality, 
Manchester,  New  Hampshire,  1917";  Mary  V.  Dempsey,  "Infant 
Mortality,  Brockton,  Massachusetts,  1918";  Emma  Duke,  "Infant 
Mortality,  Johnstown,  Pennsylvania,  1915";  Children's  Bureau, 
United  States  Department  of  Labor. 

62 


DEATH  RATES  OF  THE  FOREIGN  BORN 

a  relatively  favorable  position  among  the  foreign  bom 
in  the  community  as  regards  both  economic  and  social 
status.  .  .  .  Their  larger  death  rate  may  be  accounted 
for  by  their  large  families  and  the  prevalence  of 
artificial  feeding." 

On  the  other  hand,  the  Serbo-Croatians  in  Johns- 
town live  in  congested  and  badly  equipped  quarters, 
where  the  small  proportion  of  women  in  their  number 
bear  the  brunt  of  the  poor  housing  facilities.  How  far 
these  various  conditions  account  fully  or  in  part  for 
the  death  rates  in  different  places  and  among  dif- 
ferent races  cannot  be  asserted  except  after  further 
study.  In  any  particular  locality  it  is  evident  that 
special  study  will  be  profitable  as  a  basis  for  planning 
health  programs. 

NEED  FOR   UNIFORM  RECORDS 

All  available  morbidity  and  mortality  data  classified 
by  race  show  very  definite  differences.  These  differ- 
ences vary  with  diseases,  places,  and  ages,  but  every- 
where they  become  apparent.  Whether  these  and 
others  less  noticeable  are  due  to  racial  tendencies  or 
characteristics,  or  whether  they  are  due  to  the  various 
environments  in  which  different  race  groups  find 
themselves  in  this  country,  is  a  matter  on  which  there 
is  not  sufficient  evidence  to  support  an  opinion. 

Whatever  the  causes,  the  observed  differences  are 
sufficient  to  be  of  practical  importance  to  the  health 
officer,  the  clinical  physician,  the  visiting  nurse,  and 
all  others  concerned  with  medical  and  health  work. 
A  health  officer,  for  instance,  who  starts  a  campaign 
to  reduce  morbidity  and  mortality  from  respiratory 

diseases,  without  having  analyzed  the  race  elements 

63 


IMMIGRANT  HEALTH  AND  COMMUNITY 

in  his  community,  and  without  knowing  the  relative 
susceptibiHty  to  these  diseases  of  the  native  born,  the 
Irish,  the  Italian,  is  likely  to  waste  some  effort  and 
misdirect  much  more. 

The  most  significant  conclusion  to  be  drawn  from 
our  brief  statistical  survey  is  the  relative  paucity  of 
information.  All  the  investigations  which  have  been 
cited  make  only  a  small  contribution  to  a  few  points 
in  a  large  subject.  A  much  larger  body  of  data  should 
be  collected  before  many  final  conclusions  can  be 
stated.  Further  statistical  investigation  can  be  made 
in  two  ways:  first,  by  special  studies  undertaken  with 
particular  ends  in  view,  such  as  comparison  of  sick- 
ness or  death  rates  from  particular  diseases;  second, 
by  including  and  analyzing  the  race  elements  in  the 
masses  of  vital  statistics  which  are  more  or  less  auto- 
matically collected  by  departments  of  health  and 
many  private  organizations. 

One  of  the  most  general  difficulties  in  this  work  is 
finding  uniform  designations  for  the  so-called  race 
groups.  The  present  practice,  as  shown  in  the  reports 
of  different  health  departments,  hospitals,  dispen- 
saries, nursing,  and  other  organizations,  has  no  uni- 
formity. In  only  a  few  countries,  such  as  England, 
are  the  political  and  race  boundaries  the  same.  A 
person  born  in  Austria-Hungary  may  be  a  German, 
Magyar,  Slovak,  Bohemian,  Jew,  Croatian,  Ruma- 
nian, or  even  an  Italian.  The  inhabitants  of  that  one 
country  speak  many  tongues  and  come  to  this  country 
with  varying  heritages. 

On  the  other  hand,  mother  tongue  alone  is  not  a 

sufficient  designation.    A  person  whose  native  tongue 

is  French  may  have  been  born  in  Canada.    Either  of 

64 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  two  facts  without  the  other  is  meaningless.  Both 
must  be  given  in  order  to  complete  the  racial  picture. 
The  new  political  boundary  lines  drawn  by  the  Great 
War  will  render  *' confusion  worse  confounded"  if  both 
public  and  private  organizations  do  not  quickly  adopt 
some  uniform  system  of  recording  both  country  of 
birth  and  racial  elements.  The  following  chart  sug- 
gests a  classification  which  includes  both  the  country 
of  birth  and  the  mother  tongue. 


A    SUGGESTED    CLASSIFICATION   OF   THE    FOREIGN- 
BORN  POPULATION  BY  MOTHER  TONGUE  AND 
COUNTRY  OF  BIRTH 

Main  Headings  Represent  Mothee-tongue  Groups.  Sub- 
classes Show  the  Country  of  Birth  op  Persons  Using 
THE  Given  Mother  Tongue.  No  Countries  Represented 
in  the  United  States  by  Less  than  5,000  Persons  in  1910 
Are  Included  in  Subclasses 


Albanian 

English  and  Celtic 

Ireland 

Armenian 
Turkey  in  Asia 

England 
Canada 

Bohemian  and  Moravian 

Scotland 

Austria 

Wales 

Germany 

Australia 

T*       J               * 

West   Indies 

Bulgarian 

Bulgaria 

Finnish 

Turkey  in  Europe 

Finland 

Danish 

Russia 

Denmark 

Flemish 

Germany 

Belgium 

Dutch  and   Frisian 

French 

Netherlands 

Canada 

Germany 

France 

Esthonian 

Belgium 

Russia 

Switzerland 

66 


DEATH  RATES  OF  THE  FOREIGN  BORN 


German 

Serbo-Croatian 

Germany 

Hungary 

Austria 

Austria 

Russia 

Montenegro 

Switzerland 

Hungary 

Canada 

Slavic  Language  (Group 
not  specified) 
Austria 

Greek 

Hungary 

Greece 

Slovak 

Turkey  in  Europe 

Hungary 

Italian 

Austria 

Italy 

Slovenian 

Austria 

Austria 

Switzerland 

Hungary 

Lettish 

Spanish 

Lithuanian 

Mexico 

bpam 

Magyar 

Cuba 

Hungary 

Swedish 

Norwegian 

Sweden 

Finland 

Polish 

Russia 

Syrian  and  Arabic 

Austria 

Tm-key  in  Asia 

Germany 

Turkish 

Portuguese 

Ukrainian  (Ruthenian) 

Portugal 

Austria 

Atlantic  Islands 

Russia 

Rumanian 

Yiddish  and  Hebrew 

Rumania 

Russia 

Hungary 

Austria 

Rumania 

Russian 

Hungary 

Russia 

England 

Austria 

Germany 

67 


IMMIGRANT  HEALTH  AND  COMMUNITY 

It  may  be  hoped  that  the  census  of  the  United  States 
will  follow  the  general  principles  of  this  memorandum 
in  their  enumeration  of  "races."  Public  health  de- 
partments and  other  public  and  private  organizations 
dealing  with  medical  and  health  work  will  find  it 
simple  and  easy  to  use  in  their  routine  recording  of 
individuals,  in  birth  and  death  returns,  in  hospital 
and  dispensary  records,  and  in  the  information  gath- 
ered regularly  about  patients  by  visiting-nursing  associ- 
ations, tuberculosis  and  philanthropic  organizations. 

A  classification  based  on  mother  tongue  is,  in  prac- 
tice, simpler  to  utilize  for  the  average  nurse,  social 
worker,  or  clerk,  than  a  classification  based  on  the 
political  country  in  which  the  individual  was  born. 
It  is  easy  to  secure  the  information  from  the  patient, 
for  he  is  never  uncertain  as  to  what  language  he  spoke, 
whereas  he  is  likely  to  give  the  name  of  a  town  or  a 
district  as  the  country  of  his  nativity,  just  as  though 
an  American  traveling  abroad,  and  asked  his  nativity, 
should  reply  "Illinois"  instead  of  "The  United  States 
of  America."  Once  mother  tongue  is  ascertained,  it 
is  necessary  in  some  cases  to  find  out  the  country 
from  which  the  patient  has  come,  but  a  preceding 
question  about  mother  tongue  makes  this  more  cer- 
tain of  ready  and  correct  answer. 

The  routine  collection  of  information  about  racial 
origin,  according  to  the  system  herein  proposed,  will 
be  of  untold  value  in  connection  with  all  forms  of 
vital  statistics.  Public  and  private  organizations  will 
profit  from  it,  and  it  will  enable  us  to  pursue  many 
special  studies,  as  well  as  to  interpret  routine  statisti- 
cal reports  in  terms  of  the  important  and  neglected 

factor  of  race. 

68 


DEATH  RATES  OF  THE  FOREIGN  BORN 

It  has  not  been  our  aim  in  these  chapters  to  present 
any  final  conclusions  as  to  race  differences  in  death 
and  disease  rates,  for  the  known  facts  do  not  warrant 
such  an  attempt.  It  has  been  our  endeavor  to  point 
out  that  those  facts  which  have  been  collected  show, 
prima  faciey  that  certain  race  differences  are  of  prac- 
tical significance  for  the  medical  and  health  worker, 
the  health  officer,  and  the  administrator;  that  further 
continued  investigation  of  the  racial  factor,  and  con- 
sideration of  it  in  the  interpretation  of  most  vital 
statistics,  is  a  scientific  and  practical  necessity.  The 
need  of  uniformity  in  recording  racial  data  is  obvious, 
and  a  simple  method  of  securing  this  accuracy  and 
uniformity  has  been  suggested  for  the  consideration 
of  the  individuals  and  organizations  who  must  do  the 
work. 
6 


IV 

HOUSING   VERSUS   HEALTH 

Housing  is  such  a  fundamental  problem  that  it  re- 
quires a  more  general  review  than  a  survey  of  any 
single  community  can  give.  In  the  large  cities  where 
do  we  find  the  immigrants  living?  Down  in  the 
busiest  and  most  dilapidated  section,  from  which  the 
well-to-do  part  of  the  population  has  moved  long 
since.  Huddled  in  the  many  rooming  and  boarding 
houses  which  the  men  who  emigrate  alone  establish 
in  every  community,  jammed  into  tenements  with 
other  families,  seeing  nothing  but  the  dirty  streets, 
the  immigrant  must  find  his  life.  The  ugliest  and 
dreariest,  as  well  as  the  most  unsanitary,  portions  of 
city  housing  are  his. 

Tenement-house  life,  as  seen  by  an  immigrant  at 
first  hand,  has  been  vividly  described  by  Mr.  Ravage 
in  his  book  An  American  in  the  Making.  A  new  arrival 
in  New  York  City,  he  was  taken  in  by  a  relative  till 
he  could  gain  a  foothold  for  himself.^ 

During  the  day  my  relative  kept  up  the  interesting  fiction 
of  an  apartment  with  specialized  divisions.  ...  I  remember 
how  overwhelmed  I  was  with  this  impressive  luxury  when 
I  arrived.  But  between  nine  and  ten  o'clock  in  the  evening 
this  imposing  structure  suddenly  crumbled  away  in  the 

^  M.  E.  Ravage,  An  American  in  the  Making,  pp.  72-73. 

70 


HOUSING  VERSUS  HEALTH 

most  amazing  fashion.  The  apartment  suddenly  became 
a  camp.  The  sofas  opened  up  and  revealed  their  true 
character.  The  bureau  lengthened  out  shamelessly,  care- 
less of  its  daylight  pretensions.  Even  the  washtubs,  it 
turned  out,  were  a  miserable  sham.  The  carved  dining- 
room  chairs  arranged  themselves  into  two  rows  that  faced 
each  other  like  dancers  in  a  cotillion.  So  that  I  began  to 
ask  myself  whether  there  was,  after  all,  anything  in  that 
whole  surprising  apartment  but  beds. 

The  two  young  ladies'  room  was  not,  I  learned,  a  young 
ladies'  room  at  all;  it  was  a  female  dormitory.  The  sofa 
in  the  parlor  held  four  sleepers,  of  whom  I  was  one.  We 
were  ranged  broadside,  with  the  rocking-chairs  at  the  foot 
to  insure  the  proper  length.  And  the  floor  was  by  no 
means  exempt.  I  counted  no  fewer  than  nine  male  in- 
mates in  that  parlor  alone  one  night.  Mrs.  Segal  with 
one  baby  slept  on  the  washtubs,  while  the  rest  of  the 
youngsters  held  the  kitchen  floor.  The  pretended  chil- 
dren's room  was  occupied  by  a  man  and  his  family  of  four, 
whom  he  had  recently  brought  over,  although  he,  with 
ambitions  for  a  camp  of  his  own,  did  not  remain  long. 

Getting  m  late  after  the  others  had  retired  was  an  en- 
terprise requiring  all  a  man's  courage  and  circumspection, 
for  it  involved  the  arousing  of  an  alarmed,  overworked, 
grumbling  landlady  to  unbolt  the  doors,  the  exchange  in 
stage  whispers  of  a  complicated  system  of  challenges  and 
passwords  through  the  keyhole;  the  squeezing  through 
cracks  in  intermediate  doors,  which  were  rendered  sta- 
tionary by  the  presence  of  beds  on  both  sides;  much 
cautious  high-stepping  over  a  vast  field  of  sprawling, 
unconscious  bodies;  and,  lastly,  the  gentle  but  firm  com- 
pressing and  condensing  of  one's  relaxed  bedmates  in  order 
to  make  room  for  oneself.  It  was  on  such  occasions  as 
these  also  that  one  first  became  aware  of  how  heavy  the 
air  was  with  the  reek  of  food  and  strong  breath  and  fer- 
menting perspiration,  the  windows  being,  of  course,  her- 
metically sealed  with  putty  and  a  species  of  padding 
imported  from  home  which  was  tacked  around  all  real 
and  imaginary  cracks. 

71 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Quite  contrary  to  the  prevailing  idea  that  the  im- 
migrant deliberately  seeks  out  these  regions,  he  has 
been  driven  to  them  by  economic  necessity  and  by 
the  prejudice  of  the  native  mind  toward  him.  The 
immigrant's  attitude  toward  this  segregation  of  his 
people  is  brought  out  by  Ravage:^ 

I  know  that  the  idea  prevalent  among  Americans  is  that 
the  alien  imports  his  slums  with  him  to  the  detriment  of 
his  adopted  country,  that  the  squalor  and  the  misery 
and  the  filth  of  the  foreign  quarters  in  the  large  cities  of 
the  United  States  are  characteristic  of  the  native  life  of 
the  peoples  who  live  in  those  quarters.  But  that  is  an 
error  and  a  slander.  The  slums  are  emphatically  not  of 
our  making.  So  far  is  the  immigrant  from  being  accus- 
tomed to  such  living  conditions  that  the  first  thing  that 
repels  him  on  his  arrival  in  New  York  is  the  realization  of 
the  dreadful  level  of  life  to  which  his  fellows  have  sunk. 
And  when  by  sheer  use  he  comes  to  accept  these  conditions 
himself,  it  is  with  something  of  a  fatalistic  resignation  to 
the  idea  that  such  is  America. 

When  the  immigrant  lands  on  our  shores  at  some 
large  gate  city,  he  often  has  no  money  other  than 
the  sum  which  he  must  have  in  his  possession 
before  the  law  permits  his  entry.  Sometimes  he 
does  not  know  a  soul  on  this  side  of  the  ocean.  He 
neither  speaks  nor  understands  English.  He  must, 
then,  turn  to  cheap  quarters,  and  to  a  region  where 
others  live  who  speak  his  tongue.  These  factors, 
affecting  the  new  arrivals  for  decades,  have  built  up 
and  overcrowded  our  Little  Italics,  Polands,  and  so 
forth.  Those  who  come  seek  cheap  quarters  among 
their  own  races;  those  who  are  already  here  seek  not 
only  to  increase  their  incomes  by  taking  boarders  and 

^  M.  E.  Ravage,  An  American  in  the  Making,  p.  66. 

72 


HOUSING  VERSUS  HEALTH 

roomers,  but  also  to  help  their  fellow  countrymen  in 
establishing  themselves. 

The  great  desire  of  some  southeastern  European 
immigrants — and  in  this  respect  they  differ  somewhat 
from  the  northerners — is  to  save  money  at  any  sac- 
rifice, so  that  they  may  some  day  go  back  to  the  land 


IMMIGRANTS  FIRST  GO  TO  WVB  IN  CROWDED   DISTRICTS 
AND  OLD  HOUSES 

of  their  birth  and  live  in  ease.  Others,  who  have  left 
families  in  Europe,  save  vigorously,  not  only  to  sup- 
port them  at  home,  but  to  bring  them  to  this  land. 

A  frequent  American  attitude  toward  such  saving 
is  expressed  in  an  editorial  from  the  Boston  Transcript 
of  July  17,  1919.  The  writer  was  discussing  the  re- 
turn of  Italians  to  Italy  with  the  money  which  they 

had  saved  in  the  United  States: 

73 


IMMIGRANT  HEALTH  AND  COMMUNITY 

The  voluntarily  returning  laborer  or  trader  usually  makes 
it  a  point  to  have  laid  up  $2,000  before  he  returns  to  his 
native  country.  .  .  .  And  it  was  neither  a  very  long  nor  a 
very  difficult  matter  for  him  to  save  $2,000  in  the  United 
States.  ...  As  the  Italian  laborer's  wages  in  this  country 
have  fully  doubled,  it  would  appear  that  $5,000  is  now 
as  easy  for  him  to  get  as  $2,000  was  formerly. 

The  long  days  of  back-breaking  work,  the  nights 
spent  in  wretched  holes,  that  this  amount  might  be 
saved,  have  evidently  been  forgotten  by  the  author. 
The  object  of  such  strict  economy  is  legitimate;  the 
result  is  often  wretched  housing,  with  consequent  ill 
health  for  the  savers. 

The  presence  of  the  immigrants  in  the  tenement 
districts  of  our  cities,  forming  new  Italics,  Polands, 
and  Portugals,,  cannot  be  accounted  for  on  an  eco- 
nomic basis  alone.  They  have  been  segregated  by 
the  intolerance  of  those  who  regard  themselves  as  the 
only  real  Americans.  Real-estate  owners,  both  native 
and  foreign  born,  testify  to  this  fact.  The  foreign 
born  feel  bitter  that  they  are  not  allowed  to  rent  or 
buy  houses  in  the  better  residence  sections  of  our  cities. 

Occasionally,  by  some  mischance,  a  foreign-born 
family  does  slip  into  such  a  neighborhood.  Then  the 
native  real-estate  owner  tells  a  tale  of  woe.  Near-by 
native  tenants,  learning  of  the  invasion  by  the  foreign- 
born  American  family,  immediately  get  panicky,  con- 
clude that  "the  neighborhood  is  running  down,"  and 
move  away  to  other  regions.  Then  property  depre- 
ciates. Is  it  any  wonder  that  the  real-estate  owner 
does  all  he  can  to  keep  the  foreign  born  out  of  the 
better  residence  districts?  In  any  city  a  little  inves- 
tigation will  expose  the  fact  that  immigrant  families 

74 


HOUSING  VERSUS  HEALTH 

moving  outward  from  the  center  of  congestion  find 
themselves  following  fleeing  Americans. 

Fresno,  California,  may  be  mentioned  as  an  illus- 
tration. This  city  of  more  than  fifty  thousand  popu- 
lation lies  in  the  midst  of  an  extremely  prosperous 
and  rapidly  developing  agricultural  district,  where 
raisins  and  fruit  are  the  most  important  crops.  The 
foreign  residents  of  Fresno  were  estimated  in  1919  to 
number  twenty  thousand  or  more,  one  third  of  the 
total  population.  With  their  children  included  they 
would  constitute  more  than  one  half.  In  the  report 
on  "Fresno  Immigration  Problems,"  by  the  State 
Commission  on  Immigration  and  Housing  of  Cali- 
fornia, it  is  said  that  55  per  cent  of  the  public-school 
children  have  foreign-born  fathers.  Armenians,  Rus- 
sian-Germans, Italians,  Mexicans,  Germans,  and 
Japanese  form  the  largest  groups;  but  there  are  con- 
siderable numbers  of  Danish,  Portuguese,  Chinese, 
Swedes,  Hindus,  and  Greeks. 

One  quarter  of  the  city  is  notably  "American," 
filled  with  houses  of  the  characteristically  comfortable 
and  attractive  California  type.  The  adjoining  quarter 
on  the  same  side  of  the  railroad  track  contains  a 
number  of  less  prosperous  native  born  and  various 
other  nationalities,  but  it  is  dominated  by  the  Arme- 
nians. Houses  in  this  quarter  give  less  appearance  of 
prosperity,  but  they  are  still  comfortable.  On  the 
other  side  of  the  track,  separated  as  it  were  by  a  great 
social  gulf,  live  most  of  the  newer  incomers,  some, 
like  many  of  the  Russian- Germans,  in  tiny  houses, 
others  in  crowded  tenements  or  "barracks." 

Lines  of  social  cleavage  are  sharply  drawn  about 

the  Armenians,  who  are  probably  the  largest  single 

75 


IMMIGRANT  HEALTH  AND  COMMUNITY 

group  of  foreign  born  in  Fresno.  They  came  to  Cali- 
fornia a  generation  ago  and  have  been  successful  in 
farming  and  in  business.  Gradually  they  have  moved 
from  the  "other  side"  of  the  railroad  track  to  the 
portion  of  the  city  which  they  now  occupy.  They 
want  contact  with  native  born.  Their  prosperous 
members  endeavor  to  buy  houses  in  the  American 
quarter,  but  cannot  do  so.  A  prominent  resident  in 
Fresno  said  that  a  native-born  neighbor  of  his  could 
have  sold  his  property  to  an  Armenian  for  50  per 
cent  above  its  ordinary  value,  but  he  refused  to  do  so, 
and  he  would  have  been  socially  ostracized  by  his 
friends  if  he  had.  In  the  high  schools  the  native- 
born  children  are  rarely  allowed  to  mingle  socially 
with  Armenians. 

Race  prejudice,  language  barriers,  strange  customs 
and  manners,  have  all  had  their  share  in  this  unnatu- 
ral shutting  away  of  our  foreign-born  Americans  in 
the  dreary  districts  of  our  cities.  Wretched  and  un- 
sanitary housing  is  not  the  immigrant's  responsibility 
alone.  The  native  American  must  bear  a  large  share 
of  the  guilt. 

Improvement  of  health  and  housing  depends  not  so 
much  on  details  as  upon  the  readiness  of  people  to 
work  together  to  substitute  desirable  for  undesirable 
conditions.  Lack  of  mutual  knowledge  among  dif- 
ferent race  groups  strikes  a  body  blow  to  community 
spirit  and  renders  successful  health  work  far  more 
difficult. 

HOMES  AVAILABLE   TO   THE   IMMIGRANT 

The  quarters  which  the  new  arrival  finds  available  to 

him  are,  in  general,  of  three  types:  First,  the  large  old 

76 


HOUSING  VERSUS  HEALTH 

houses,  once  occupied  by  the  better-to-do  element  of 
our  cities,  which  have  been  more  or  less  remodeled  to 
meet  the  new  demands;  second,  the  tenements  which 
have  been  built  especially  for  the  immigrant;  and 
third,  the  houses  erected  by  industry  for  their 
employees. 

The  first  of  these  provide  probably  the  most 
wretched  living  conditions.  Built  originally  as  spa- 
cious homes  for  small  families,  they  are  ill  adapted 
to  remodeling  for  large  numbers  of  people.  They  had 
large  rooms,  windows  for  light  and  ventilation,  ram- 
bling, connecting  spaces,  airy  hallways,  and  but  few 
toilets  and  washing  facilities.  When  these  structures 
are  turned  into  tenements,  what  happens? 

Sometimes  practically  no  alteration  is  made,  and 
many  families  must  live  under  conditions  suitable  for 
only  one.  More  frequently,  changes  are  instituted. 
The  big  airy  rooms  are  divided  into  many  small  ones. 
Thus  the  lighting  and  ventilating  capacity  of  the 
original  windows  is  lost,  and  dark  rooms  with  no  out- 
side ventilation  are  formed.  Toilets  are  built  into 
the  narrowed  and  darkened  hallways,  and  faucets  are 
put  in  on  each  hall  floor  for  the  common  use  of  the 
tenants.  Into  these  patched-up  structures  crowd  the 
immigrants,  accustomed  to  the  outdoors  and  agri- 
cultural life,  ignorant  of  urban  sanitation  and  toilet 
facilities. 

The  tenements  are,  as  a  rule,  a  step  better  than 
these  remodeled  houses,  although  they  have  insufficient 
allowance  for  sunlight  and  air  as  well  as  inadequate 
toilets  and  washing  conveniences.  Only  too  often 
model  tenements  erected  for  the  foreign  born  come 

to  be  occupied  by  the  semiprofessional  class,  such  as 

77 


IMMIGRANT  HEALTH  AND  COMMUNITY 

clerks,  social  workers,  and  teachers,  and  so  do  not 
serve  as  demonstrations  in  housing  and  sanitation 
for  those  who  are  unfamiliar  with  American  conditions. 

Houses  constructed  by  industrial  concerns  for  their 
employees  furnish  an  interesting  study.  Great  im- 
petus has  been  given  to  this  activity  by  the  housing 
program  pursued  by  the  United  States  government 
during  the  war.  Permanent  villages  were  built  around 
the  industrial  establishments  which  were  likely  to 
endure  after  the  war,  and  many  temporary  ones  were 
erected  elsewhere.  These  villages  grew  out  of  the 
imperative  war-time  demand  for  stable  labor  forces. 
Without  decent  and  adequate  housing  labor  could  not 
be  induced  to  stay  long  in  one  place,  so  millions  were 
spent  by  the  United  States  government  to  this  one  end. 

For  many  years,  however,  certain  industries  have 
felt  the  great  need  of  decent  housing  for  their  em- 
ployees, and  have  made  attempts  to  secure  it.  The 
houses  found  in  certain  isolated  mining  regions  are 
examples.  In  some  parts  of  the  East  whole  villages 
have  been  developed  by  the  chief  local  industry. 
Whitinsville,  Massachusetts,  is  a  case  in  point.  The 
more  recent  plan  is  to  build  houses  for  employees  on 
easy  payments,  so  that  the  individual  industry  does 
not  own  the  worker  body  and  soul.  The  kind  of 
houses  built,  and  the  number  of  modern  conveniences 
in  them,  depend  on  the  degree  of  enlightenment  of 
the  industry,  on  its  size,  and  somewhat  on  its  location. 

PREVALENT   TENEMENT    CONDITIONS 

The  preliminary  report  of  the  tenement-house  survey 
of  New  York  City,  made  in  1919  by  the  Reconstruc- 

78 


HOUSING  VERSUS  HEALTH 

tion  Commission  of  the  state  of  New  York,  depicts 
prevalent  conditions :  ^ 

By  the  time  this  work  is  completed  we  will  have  visited 
1,700  houses,  consisting  of  about  34,000  apartments, 
accommodating  between  175,000  and  200,000  persons. 

In  innumerable  instances  families  are  crowded  together 
in  dark,  ill-smelling  apartments  and  are  unable  to  find  other 
quarters.  .  .  .  To  a  great  extent  vacancies  exist  in  Italian 
and  other  foreign  districts.  There  has  been  practically  no 
immigration  during  the  past  few  years.  During  this  time 
a  great  many  of  the  inhabitants  of  the  Italian  sections  in 
the  lower  and  upper  East  Side  went  abroad  to  fight  for  their 
country. 

Thus  it  is  evident  that  the  immigrants  who  have  once 
known  better  quarters  than  the  slums  cannot  be  induced 
to  live  in  them  again.  It  is  in  the  regions  occupied  by  the 
newly  arrived  immigrants  that  the  most  miserable  tene- 
ments are  found.  ...  It  is  apparent  that  one  who  has 
become  accustomed  to  the  comparatively  better  conditions 
in  the  Bronx  and  upper  Manhattan  cannot  be  induced  to 
return  to  these  portions  of  the  city  where  the  old,  dark 
tenements  are  in  such  abominable  repair.  .  .  ,  All  of  these 
apartments  have  interior,  dark  rooms,  but  these  exist  in 
practically  every  neighborhood  that  was  investigated  by 
the  committee.  In  a  block  in  the  East  Forties  vacancies 
existed  in  houses  of  a  similar  type.  Very  often  they  were 
caused  by  a  lack  of  proper  sanitary  and  toilet  facilities. 
These  were  situated  very  often  in  the  yards  and  were  used 
by  a  number  of  families.  The  rooms  in  the  vacant  apart- 
ments are  dark  and  in  many  cases  damp.  Practically  all 
the  houses  were  in  need  of  repair. 

Certain  of  the  conditions  that  were  found  to  exist  in 
practically  every  block  can  be  remedied  by  better  manage- 
ment. These  include  lack  of  repairs,  such  as  walls  with- 
out plastering,  walls  needing  painting,  dirty  halls,  courts, 

*  Address  of  Abram  I.  Elkus,  chairman,  before  a  meeting  of  the 
Reconstruction  Commission  of  the  state  of  New  York  on  June  9, 
1919. 

79 


IMMIGRANT  HEALTH  AND  COMMUNITY 

and  yards,  and,  above  all,  unsanitary  conditions  brought 
about  through  lack  of  care  of  toilets. 

A  study  of  a  block  in  the  East  Forties  gives  some  very 
good  examples  of  conditions  difficult  to  remedy.  The 
thirty-six  tenement  houses  in  this  block  are  all  old  brick 
houses  built  before  1901  and  showing  all  the  evils  of  the 
"old  law"  tenement  construction.  The  lighting  is  par- 
ticularly bad.  Of  some  1,200  rooms  in  the  block,  600  have 
indirect  lighting — that  is,  they  have  no  windows  opening 
to  the  outer  air,  only  the  so-called  windows  opening  on  to 
another  room.  Of  the  other  600  rooms,  only  half  have 
windows  to  the  street.  The  others  open  on  a  back  yard 
or  on  a  court.  Of  course,  these  600  dark  rooms  must  be 
used.  In  almost  every  case  they  are  bedrooms.  It  is 
evident  that  at  least  600  people  and  probably  a  great 
many  more,  since  at  least  one,  often  two,  three,  and  some- 
times four  people  sleep  in  these  dark  bedrooms,  are  com- 
pelled to  sleep  under  unsanitary  conditions,  no  matter 
how  well  they  keep  their  apartments.  There  are  apart- 
ments of  three  and  four  rooms,  arranged  in  corridor  fashion 
— that  is  to  say,  each  succeeding  room  depending  on  the 
last  for  the  exit  and  entrance.  On  the  plans  filed  with  the 
Tenement  House  Department,  these  rooms  would  be 
labeled  successively  parlor,  dining  room,  living  room,  with 
toilet  adjoining,  and  bedroom.  Where  only  the  last  room 
is  used  as  a  bedroom,  proper  conditions  would  exist,  but 
they  cannot  if,  as  is  invariably  the  case,  the  so-called 
parlor  and  dining  room  and  often  the  kitchen  are  used  as 
sleeping  quarters. 

The  notable  work  of  the  California  Commission  on 
Immigration  and  Housing  in  improving  such  condi- 
tions is  discussed  later. 


BOARDERS  IN  EVERY  THIRD  FOREIGN-BORN  HOME 

The  crowded  conditions  under  which  the  immigrants 

live  were  attested  beyond  dispute  by  the  United 

80 


HOUSING  VERSUS  HEALTH 

States  Immigration  Commission  Report  in  1909.*  The 
commission  secured  information  from  more  than  17,- 
000  households  in  industrial  localities.  Among  the 
households  whose  heads  were  native  born  the  average 
number  of  persons  per  sleeping  room  was  1.92,  as 
contrasted  with  2.53  among  those  whose  heads  were 
foreign  born.  The  following  table  shows  the  per  cent 
of  households  of  each  nativity  group  which  kept 
boarders  or  lodgers. 


TABLE  XVin 

Per  Cent  of  Households  Keeping  Boarders  or  Lodgers  by 
General  Nativity  and  Race  of  Head  of  Household  ^ 


Nativity  op  Head  op  Househoij) 


Native  born 

Native  born  of  foreign  father. 
Foreign  born 


Croatian 

Lithuanian 

Ruthenian 

Magyar 

PoHsh 

Slovak 

Italian — ^North 

South 

German 

Canadian,  French 

Irish 

Bohemian  and  Moravian. 
Hebrew 


Per  Cent 


9.9 
10.9 
32.9 

59.5 
57.6 
56.9 
53.6 
48.4 
36.0 
34.2 
33.5 
16.2 
15.4 
14.8 
8.8 
8.4 


Only  those  nationalities  are  included  in  the  table  of 
which  500  or  more  households  were  studied. 

The  table  brings  out  the  fact  that  the  households 

*  Jenks  and  Lauck,  The  Immigration  Problem,  1913,  Table  VI, 
p.  457.  2 11^^^  Appendix  E,  p.  459. 

81 


IMMIGRANT  HEALTH  AND  COMMUNITY 

which  take  the  greatest  number  of  boarders  or  roomers 
are  the  latest  comers  from  eastern  and  southeastern 
Europe.  The  Croatians,  Lithuanians,  Ruthenians, 
Magyars,  and  Poles  show  a  high  percentage.  In  the 
tables  from  which  the  above  extracts  were  made  the 
Serbians  and  Rumanians  showed  extremely  high  per- 
centages, but  they  were  based  on  less  than  a  hundred 
families  and  so  have  not  an  adequate  basis  for  com- 
parison. In  the  more  recent  immigration  the  young 
men  come  alone,  those  with  families  bringing  them 
over  in  later  years.  This  is  especially  true  among  the 
Greeks,  the  Balkan  races,  and  the  peoples  of  Asia 
Minor.  The  communal  system  of  living  practiced  by 
these  men  leads  to  serious  overcrowding. 

Of  the  15,127  households  of  the  foreign  born  in- 
cluded in  the  Federal  study,  34  per  cent  had  seven  or 
more  persons  per  household,  as  against  13.8  per  cent 
of  the  native  born  of  native  parents.  Nine  and  one 
tenth  per  cent  of  the  foreign  born  had  ten  or  more  per 
household  as  against  1.2  per  cent  of  the  natives.  It 
is  apparent  that  this  congestion  among  our  foreign- 
born  population  must  work  for  serious  impairment  of 
health. 

AMERICAN  HOUSING  VERSUS  IMMIGRANT  HEALTH? 

What  effect  on  the  health  of  the  immigrant  have  the 
unsanitary  housing  conditions  to  which  he  must  sub- 
mit in  this  country?  Inadequate  washing  facilities 
mean  unclean  bodies,  homes,  and  clothing.  Over- 
crowding means  aggravation  of  these  evils,  as  well  as 
the  rapid  spread  of  contagious  diseases,  like  tubercu- 
losis or  diphtheria.     Lack  of  knowledge  as  to  the 

proper  use  of  toilets  leads  to  their  fouling  as  well  as 

82 


HOUSING  VERSUS  HEALTH 

the  contamination  of  the  entries  and  halls.    Too  little 
fresh  air  and  sunlight  brings  lack  of  bodily  vigor. 

Data  secured  by  the  Children's  Bureau  in  its  study 
of  infant  mortality,  in  JohnstowTi,  Pennsylvania,  pre- 
sent further  evidence  of  the  ill  health  resulting  from 
bad  housing.^ 

An  absolute  measure  of  the  importance  of  each  housing 
defect  in  a  high  mortality  rate  camaot  be  secured  from  this 
study.  But  it  is  not  without  interest  to  note  that  in  homes 
where  water  was  piped  into  the  house  the  infant  mortality 
rate  was  117.6  per  thousand,  as  compared  with  a  rate  of 
197.9  in  homes  where  the  water  had  to  be  carried  in  from 
outdoors.  In  the  homes  of  496  live-born  babies  the  infant 
mortality  rate  where  bathtubs  were  found  was  72.6,  while 
it  was  more  than  double,  or  16-4.8,  where  there  were  no 
bathtubs.  Desirable  as  a  bathtub  and  bodily  cleanliness 
may  be,  this  does  not  prove  that  the  lives  of  the  babies 
were  saved  by  the  presence  of  the  tub  or  the  assumed 
cleanliness  of  the  persons  having  them.  In  a  city  of 
Johnstown's  low  housing  standards  the  tub  is  an  index 
of  a  good  home,  a  suitable  house  from  a  sanitary  standpoint, 
a  fairly  comfortable  income,  and  all  the  favorable  conditions 
that  go  with  such  an  income. 

In  homes  of  one,  two,  three,  or  four  room^,  or  where 
the  number  of  occupants  ranged  from  4.42  to  1.58  persons 
per  room,  the  infant  mortality  rate  was  155,  as  compared 
with  a  rate  of  but  101.8  in  larger  homes,  where  the  number 
ranged  from  1.22  to  0.43  persons  per  room. 

The  1910  census  returns  show  that  the  greatest  over- 
crowding was  in  ward  15,  where  the  average  number  of 
persons  per  dwelling  was  9.9.  Wards  16,  11,  and  14  came 
next,  with  averages  of  8.3,  7.7,  and  7.2,  respectively.  The 
infant  mortality  rate  for  these  four  wards  is  190.2,  which 
is  over  one  third  more  than  the  rate  for  the  whole  city. 

^Emma  Duke,  "Infant  Mortality,  Johnstow-n,  Pennsylvania," 
Bulletin  No.  9,  Children's  Bureau,  United  States  Department  of 
Labor,  1915. 

83 


IMMIGRANT  HEALTH  AND  COMMUNITY 

The  Manchester  study,  made  by  the  same  bureau 
in  1917,  brought  out  similar  points.^ 

Conditions  in  and.  around  alley  and  rear  houses  were 
found  by  the  agents  to  be  almost  uniformly  bad,  and  the 
infant  mortality  rate  for  babies  in  such  houses  was  high. 
Live-born  babies  in  these  houses  numbered  123,  or  7.9 
per  cent  of  the  whole  number.  These  babies  died  at  the 
rate  of  227.6  per  1,000,  while  the  death  rate  among  babies  in 
homes  with  a  street  frontage  was  only  159.4. 

The  infant  mortality  rate  showed  a  steady  increase 
accorduig  to  the  number  of  persons  per  room.  It  was 
123.3  where  the  average  was  less  than  1;  177.8  where  the 
average  was  1  but  under  2;  and  261.7  where  the  average 
was  2  but  less  than  3. 

Such  figures  as  these  are  convincing  evidence  of  the 
serious  menace  which  bad  housing  presents  to  the 
immigrant. 

One  of  our  health  oflScers  has  thus  explained  why 
American  housing  is  usually  versus  the  immigrant's 
health  :2 

Congestion,  the  crowding  of  large  numbers  of  persons 
upon  a  small  area  and  of  families  into  cramped  dwelling 
quarters,  favors  communication  of  diseases,  uncleanliness, 
and  inadequate  ventilation.  .  .  .  These  influences  show 
statistically  in  infant  mortality  and  the  death  rates  from 
tuberculosis  and  other  diseases. 


TESTIMONY    OF    HEALTH    OFFICERS 

The  attitude    of  American  health  agencies    toward 
the  housing  problems  of  the  immigrant  will  be  im- 

1  Beatrice  Sheets  Duncan  and  Emma  Duke,  "Infant  Mortality, 
Manchester,  New  Hampshire,  1917,"  Children's  Bureau,  United 
States  Department  of  Labor. 

2  J.  S.  McNutt,  A  Manual  for  Health  Officers,  1915,  p.  512 

84 


HOUSING  VERSUS  HEALTH 

portant  in  determining  their  solution.  A  series  of 
questionnaires  sent  to  261  health  departments  in  cities 
in  the  United  States  which  had  large  foreign-born 
populations  brought  replies  from  142  cities.  The 
pf  oblems  of  housing  and  home  sanitation  were  giving 
serious  concern  to  74  of  these  health  officers — 52  per 
cent  of  all  who  answered.  In  contrast  to  this  the 
contagious-disease  problem,  which  is  usually  of  such 
paramount  importance  to  health  departments,  was 
spoken  of  in  only  37  questionnaires,  or  26  per  cent. 

Some  of  the  officers  claimed  that  the  immigrants 
deliberately  seek  out  the  worst  housing  locations  so 
that  they  can  annoy  the  officers  of  the  law  by  violat- 
ing all  sanitary  codes.  Asked  what  problems  had 
been  met  in  his  experience  as  health  officer  in  dealiug 
with  the  foreign  born,  one  man  answered,  "  Ignorance 
and  willful  violation  of  all  health  rules.*'  Another 
writes: 

The  average  Italian  .  .  .  lives  in  colonies  in  the  old 
tumble-down  districts  of  the  city.  [They]  are  clannish, 
followLQg  many  of  the  old  native  country  fashions,  and, 
above  all,  cannot  be  made  to  appreciate  the  personal 
and  economic  value  of  a  general  clean-up  and  stay  clean. 

For  others  the  immigrant  seems  to  represent  a  race 
apart,  quite  different  from  all  others  when  it  comes  to 
questions  of  sanitation  and  housing.  One  of  this  group 
— after  referring  to  the  "Dagoes"  and  "Polacks"  in 
his  community — said  there  was  "great  need  of  cleanli- 
ness," but  that  "very  little  had  been  accomplished." 
One  reason  for  this  man's  failure  is  apparent  in  the 
very  tone  of  the  reply.  Another  claims  that  "there 
are  no  laws  of  sanitation  and  living  by  the  average 

foreign-born  family."  Another  makes  the  sweeping  ac- 
7  85 


IMMIGRANT  HEALTH  AND  COMMUNITY 

cusation  that  the  immigrant  is  unable  *'to  understand 
what  constitutes  sanitation."  It  is  not  unlikely  that 
the  immigrant's  inability  to  understand  is  here  due  to 
the  health  officer's  antagonizing  those  whom  he  wished 
to  reach,  instead  of  employing  educational  methods. 


IN  PEASANT  COUNTRIES  BATHING  AND  WASHING  WERE  DONE 

OUT  OF  DOORS 

Some  health  officers  have  recognized  the  need  of  the 
foreign  born  for  education  in  the  sanitary  care  of  houses. 

Our  foreign  population  is  being  instructed  in  sanitation 
through   the   Health  Department,   the   District  Nursing 

86  ^ 


HOUSING  VERSUS  HEALTH 

Association,  and  the  school  nurse.  These  branches  seem 
to  me  to  be  the  best  fitted  for  this  work  as  they  have  direct 
access  to  the  homes  of  the  foreigner  when  called  in  cases 
of  illness  and  contagious  disease. 

Another   group    whose   attitude   was   investigated 


IS  IT  ANY  WONDER  IT  TAEIES  TIME   TO   I»EARN   TO   USE 
A  BATHTUB? 

was  the  industrial  physicians.  Of  the  80  replies  re- 
ceived, there  were  only  22  who  spoke  of  the  im- 
portance of  housing  in  relation  to  the  eflBciency  of 

the  foreign-bora  employee.    Many  of  these  22  felt 

87 


IMMIGRANT  HEALTH  AND  COMMUNITY 

that  bad  housing  conditions  should  be  corrected  by- 
community  action  rather  than  by  industrial. 

One  doctor  spoke  of  trying  to  get  his  "people  out 
of  basements"  as  a  good  housing  measure.  Another 
wrote  that  the  "foreign  born  should  not  live  in  clans, 
but  mingle  with  the  native  race,"  a  rather  interesting 
remark  when  one  recalls  the  attitude  of  the  average 
member  of  the  "native  race"  toward  this  question. 
Still  another  physician  thinks  that  "the  tendency  of 
the  foreign  born  to  live  in  colonies  and  to  patronize 
in  a  business  and  professional  way  only  those  speaking 
their  own  language  .  .  .  are  practices  that  militate 
against  rapid  Americanization."  This  man  has  evi- 
dently not  given  much  thought  to  the  cause  of  this 
tendency  to  colonize.  His  cure  for  it  is  to  teach  the 
foreign  born  the  English  language.  He  advocates 
penalizing  industries  which  employ  non-English- 
speaking  workmen,  as  well  as  the  men  themselves. 

More  thoughtful  answers  indicated  a  desire  to  seek 
industrial  as  well  as  community  solutions.  One  ad- 
vocates "careful  supervision  of  housing  conditions  by 
nurses  and  doctors."  Another  suggests:  "Provide 
good  housing.  Create  and  foster  a  community  spirit, 
stimulating  initiative."  A  third  writes  that  his  com- 
pany is  "instructing  them  [the  foreign-bom  workers] 
in  the  Building  Association  plan  of  purchasing  their 
own  homes  instead  of  rooms  and  tenements."  Most 
of  the  physicians  felt  the  need  of  nurses  to  do  educa- 
tional work  in  sanitation  and  hygiene  in  the  homes. 

Abram  I.  Elkus,  chairman  of  the  Reconstruction 
Commission  of  the  state  of  New  York  in  1919,  sum- 
marized in  his  report  the  problem  of  housing  our  im- 
migrants in  New  York  City.    After  a  discussion  of 

88 


HOUSING  VERSUS  HEALTH 

the  preliminary  findings  of  the  tenement-house  survey 
made  by  this  commission,  he  said,  in  conclusion: 

We  must  decide  on  a  housing  policy.  We  must  look  the 
whole  problem  straight  in  the  eye.  We  must  find  a  way 
out.  We  have  spoken  of  American  standards  of  living, 
and  look  at  the  kind  of  homes  we  give  to  the  newly  arrived 
immigrant.  The  landlord  of  one  of  the  houses  that  had 
subagencies  said  to  one  of  our  investigators  that  he  would 
have  no  trouble  in  filling  his  house  when  immigration  had 
again  started.  What  is  the  use  of  talking  of  Americaniza- 
tion and  education  if  the  people  of  this  city  are  to  be  forced 
to  live  in  the  homes  that  are  being  pictured  by  our  block 
surveys?  It  is  time  that  we  should  look  at  this  matter 
clearly. 

BETTER  HOUSING 

First,  decent  buildings,  with  adequate  modern  con- 
veniences, should  be  erected  by  private  interests, 
communities,  or  industries.  This  is  not  the  time  to 
decide  who  shall  do  it,  but  to  get  it  done.  The  com- 
munity itself  must  either  control  them  absolutely  or 
retain  sufficient  reserve  power  to  insure  proper  stand- 
ards of  construction  and  maintenance,  both  of  indi- 
vidual buildings  and  of  entire  building  schemes  in  re- 
lation to  town  planning. 

There  is  a  great  opportunity  here  for  the  native 
born  to  co-operate  with  our  new  Americans  in  making 
and  executing  building  plans.  Each  race  coming  to 
our  shores  brings  with  it  a  building  experience  of  its 
own  as  well  as  an  appreciation  of  beauty  in  archi- 
tecture. A  recent  report  of  the  American  Red  Cross 
Commission  to  Italy  includes  a  section  devoted  to 
"Housing  in  Italy,"  where  this  point  is  elaborated:^ 

^  Mildred  Chads[ey, "  Housing  in  Italy,"  Report  of  the  Commission 
for  Tuberculosis,  American  Red  Cross  in  Italy,  pp.  2,  3. 

89 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Americans  might  learn  much  from  Italians,  who,  through 
centuries  of  experience  in  building-  and  in  seeing  examples 
of  building  for  people  who  live  in  groups,  develop  better 
plans  for  multiple  dwellings  than  Americans.  They  might 
get  suggestions  for  city  tenements  built  about  courts 
that  would  not  present  the  hideous  rear  view  that  makes 
parts  of  some  cities  like  New  York  and  Chicago  look  like 
wildernesses  of  back  stairs  and  clotheslines,  and  would 
afford  a  better  place  for  assembling  and  outdoor  work  than 
the  street  in  front  of  the  tenement.  .  .  . 

American  housing  experts  who  prepare  our  building 
and  sanitary  codes  might  learn  from  Italians  the  value 
of  such  sections  as  the  following,  taken  from  the  Roman 
code: 

It  is  forbidden  to  paint  the  doors  and  windows  of  the 
building  with  colors  that  are  out  of  harmony  with  the  tint 
of  the  walls  of  the  building. 

The  color  of  the  outside  of  buildings  facing  public  streets 
must  be  harmonious  and  uniform  for  the  entire  length  of 
the  wall.  In  case  of  disagreement  on  the  color  to  be  used, 
the  communal  authorities  shall  decide. 

In  buildings  and  in  villas  having  special  artistic  or  his- 
torical character,  it  is  forbidden  to  make  alterations  which 
shall  threaten  in  any  way  their  aesthetic  value. 

Do  not  such  regulations  as  these,  self-imposed  by 
the  Italian  people,  point  to  their  inherent  love  of 
beauty  in  housing  and  their  respect  for  its  preserva- 
tion? Yet,  considering  the  Italian  immigrants  as 
they  crowd  into  our  slums,  the  native  born  are  too 
apt  to  lose  sight  of  this  significant  point.  To  recognize 
and  utilize  such  heritages  as  these  would  result  in 
mutual  respect  and  increased  understanding. 

Second  in  the  solution  of  the  housing  problem, 
many  foreign  born  will  need  education  in  the  use  of 
decent  houses,  so  that  they  will  not  be  abused.  To 
be  successful  this  education  must  be  undertaken  in  a 

90 


HOUSING  VERSUS  HEALTH 

co-operative  spirit.  The  customs  of  the  group  con- 
cerned must  be  understood,  their  reaction  to  their 
new  dwellings  carefully  watched,  and  the  educational 
process  adapted  to  their  particular  needs.  The  whole 
problem  of  educating  the  foreign  born  in  hygiene  is 
so  involved  with  this  matter  of  method  that  we  must 
return  to  it  toward  the  end  of  the  book  after  other 
elements  have  been  introduced. 

Third,  the  most  important  and  most  difficult  factor 
of  all  is  the  necessity  for  changing  the  point  of  view  of 
the  native  American  toward  this  whole  question.  It 
must  be  altered  fundamentally.  The  foreign  born 
must  not  be  regarded  as  a  neighbor  to  be  kept  at  arm's 
length,  but  as  a  neighbor  to  be  really  lived  with.  Only 
by  human  contact  can  we  hope  to  assimilate  our  new 
Americans  into  our  national  life.  The  housing  prob- 
lem involves  the  most  important  sanitary  and  health 
relationships,  but  its  difficulties  largely  arise  from  a 
combination  of  economic  conditions  with  social  preju- 
dices and  misunderstandings.  Its  solution  is  impos- 
sible on  either  a  philanthropic  or  a  business  basis 
alone,  or  by  any  combination  of  the  two,  unless  a 
broad  foundation  of  human,  neighborly  understand- 
ing underlies  the  whole  endeavor. 


SELF-HELP  AND   HEALTH 

It  is  little  realized  that  immigrants  have  extensively 
developed  organizations  for  aid  in  time  of  illness 
which  function  quite  independently  of  any  American 
agency.  Frequently  in  small  communities  wherein 
native  Americans  must  depend  upon  their  individual 
resources  in  time  of  sickness,  and  wherein  publicly 
organized  facilities  are  inadequate  or  nonexistent, 
the  foreign  born  will  have  well-defined  organiza- 
tions for  sickness  and  death  insurance  and  for 
medical  care. 

This  capacity  for  co-operation  is  an  inheritance 
which  most  of  our  foreign  bom  bring  with  them  from 
Europe.  Many  of  the  southeastern  Europeans,  nota- 
bly the  Italians,  have  been  members  of  local  or  vil- 
lage co-operative  associations  at  home,  which  they 
continue  in  this  country.  Almost  all  of  these  associa- 
tions, although  they  may  be  formed  for  other  pur- 
poses—  social,  cultural,  or  political  —  include  some 
scheme  for  sickness  and  death  insurance. 

It  is  well  to  dwell  upon  the  contrast  between  native 

and  foreign  born  in  this  respect,  but  we  should  by  no 

means  leap  to  the  conclusion  that  because  of  the 

prevalence  of  sick  and  death  benefit  societies  among 

the  foreign  born,  they  are  fully  protected  against  the 

92 


SELF-HELP  AND  HEALTH 

emergencies  of  illness.  Far  from  it.  We  must  inves- 
tigate not  only  the  extent  of  service  rendered  by  these 
societies,  but  also  its  adequacy  and  eflficiency. 

RACIAL  BASIS  OF  BENEFIT   SOCIETIES 

To  secure  information  in  regard  to  the  organizations 
of  the  foreign  born  is  difficult.  The  data  presented 
here  have  been  gleaned  between  the  Atlantic  and 
Pacific  coasts  through  many  interviews  with  foreign- 
born  doctors,  doctors  and  members  of  fraternal 
societies,  and  from  various  articles  and  reports,  par- 
ticularly those  of  the  Pennsylvania,  Ohio,  and  Illinois 
Health  Insurance  Commissions.  It  is  fragmentary, 
but  it  indicates  the  extent  to  which  the  foreign  born 
have  organized  for  protection  against  sickness. 

Benefit  societies  are  found  in  great  numbers  and 
are  of  much  importance  among  the  races  of  the  new 
immigration  —  the  Slavs,  Italians,  Magyars,  Jews, 
Greeks,  and  Portuguese.  They  are  usually  racial  in 
origin,  founded  on  common  language  and  heritages. 
In  the  United  States  benefits  for  illness  and  death 
play  a  significant  part  in  membership.  These  organi- 
zations are  such  an  important  factor  in  the  lives  of 
the  immigrants  that  American  medical  and  health 
agencies  should  recognize  and  co-operate  with  them 
as  far  as  possible. 

The  data  and  the  impressions  secured  by  our  in- 
vestigators furnish  confirmatory  and  illustrative 
material  from  a  considerable  number  of  different 
communities  in  various  parts  of  the  country.  For 
our  purposes   we   have   roughly   classified    societies 

among  the  foreign  born  which  include  benefit  fea- 

93 


IMMIGRANT  HEALTH  AND  COMMUNITY 

tures   into   four   groups,   according   to   their    chief 
reason  for  existence. 


FOUR  TYPES   OF  BENEFIT   SOCIETIES 

One  type  is  based  upon  national  or  group  conscious- 
ness. Of  this  the  "PoHsh  National  Alliance  "  and  the 
Jewish  "B'nai  B'rith"  are  examples.  A  major  pur- 
pose of  these  societies  is  to  keep  alive  the  love  of  the 
homeland  or  of  the  race  tradition  and  to  aid  in  secur- 
ing freedom  from  oppression  for  their  fellow  nationals 
in  Europe.  These  societies  usually  have  a  large 
membership  and  are  influential. 

A  second  type  might  be  classed  as  fraternal  or- 
ganizations, such  as  the  Loyal  Order  of  Moose,  the 
Foresters,  or  the  Fraternal  Order  of  Eagles,  some  of 
which  are  international  in  influence.  We  usually 
think  of  these  as  American  institutions,  but  many 
foreign  born  belong  to  them,  and  there  are  lodges 
whose  whole  membership  is  foreign  born.  They  are 
not,  however,  typical  of  societies  developed  by  the 
immigrants  themselves  for  self-aid. 

Societies  of  another  type,  highly  developed  among 
the  Poles  and  Lithuanians,  are  connected  with  the 
churches.  Mr.  Horak  remarks  in  the  report  of  the 
Health  Insurance  Commission  of  Illinois: 

Contrary  to  the  general  impressions,  relatively  few 
societies  are  connected  with  churches  or  have  a  definitely 
religious  aspect.  The  chief  exceptions  are  among  the 
Italians  and  some  of  the  German  societies.  It  should  be 
said,  too,  that  the  Catholic  churches  without  regard  to 

*  Report  of  the  Health  Insurance  Commission  of  Illinois^  May  1, 
1919,  p.  5U. 

94 


SELF-HELP  AND  HEALTH 

race  have  benefit  organizations  within  them,   but  these 
have  found  no  particular  place  in  this  study. 

The  investigations  made  by  this  study  in  several 
localities  other  than  Chicago  establish  the  connection 
between  certain  racial  societies  and  the  church. 
The  Pennsylvania  Health  Insurance  Commission  also 
reports  several  church  organizations  as  carriers  of 
insurance  in  that  state.  Among  them  might  be  men- 
tioned the  "Lithuanian  Roman  Catholic  Alliance  of 
America,"  the  "South  Slovenia  Catholic  Union,"  and 
the  "  Slavonic  Evangelical  Union  of  America. "  These 
societies  come  into  being  primarily  for  social  purposes 
and  aid  in  sickness  is  a  secondary  function.  There 
may  be  several  such  societies  in  a  single  parish. 

The  fourth  group,  reaching  intimately  immigrants 
from  eastern  and  southeastern  Europe — comprises  the 
small  local  societies  to  be  found  wherever  the  foreign 
born  have  settled.  The  locals  of  trade-unions  might 
be  included  in  this  group,  although  they  give  little  aid 
in  sickness.  These  societies  have  two  general  reasons 
for  existence,  the  proximity  in  this  country  of  in- 
dividuals who  speak  the  same  language  and  have  the 
same  racial  heritage,  and  their  common  origin  in  some 
village  or  town  in  Europe.  These  societies  range  in 
size  from  25  members  to  700  or  800;  and  as  many  as 
300  societies  among  a  single  race  may  be  found  in 
some  of  our  large  cities.  One  hundred  such  Italian 
societies  are  reported  to  exist  in  Boston. 

GENERAL   CHARACTER   OF   SOCIETIES 

Most  of  these  organizations  were  formed  for  social 

and  cultural  purposes.    The  insurance  feature,  how- 

95 


IMMIGRANT  HEALTH  AND  COMMUNITY 

ever,  has  become  very  important  with  increased 
familiarity  with  the  exigencies  of  life  in  the  United 
States.  Through  these  organizations  both  death  and 
sickness  benefits  are  extended  to  members. 

Many  employ  a  doctor  to  examine  all  applicants  for 
membership,  and  all  members  applying  for  sick  bene- 
fits. Others,  however,  do  not  bother  with  a  special 
doctor.  The  member  may  choose  his  own  physician 
and  the  society  will  pay  a  set  amount  for  each  ex- 
amination or  visit  of  that  doctor.  In  some  societies 
medical  services  are  included,  not  only  for  members, 
but  for  their  families  as  well.  In  others  the  doctors 
employed  by  the  society  give  free  service  to  society 
members  only,  but  charge  reduced  rates  to  families. 

Sick  benefits  are  subject  to  several  limitations  in 
most  societies,  such  as  that  one  week  of  illness  must 
elapse  before  benefits  are  paid,  and  that  membership 
in  the  society  for  a  year  is  required  before  application 
for  sick  benefit  is  allowed.  A  two  weeks'  membership 
usually  secures  the  death  benefit.  In  some  societies 
the  dues  are  graduated  according  to  age,  increasing  in 
amount  with  the  years. 

Most  of  these  societies  admit  men  only  to  member- 
ship, some  admit  men  and  women,  and  some  women 
only.  The  relative  scarcity  of  women  members  re- 
flects the  attitude  of  the  men  of  the  new  immigration 
toward  their  womenfolk.  Among  the  Italians  and 
Poles  there  are  numerous  women's  societies  organized 
chiefly  for  intellectual  or  cultural  purposes.  Benefits 
are  attached,  but  they  are  of  secondary  importance. 

The  number  of  societies  to  which  an  individual 
may  belong  is  limited  only  by  the  size  of  his  pocket- 
book.    An  Italian,  for  example,  may  belong  to  one 

96 


SELF-HELP  AND  HEALTH 

national  organization  and  several  district  or  village 
societies  in  which  he  may  have  a  right  to  membership. 
Dues  must  be  paid  to  each,  and,  in  case  of  illness  or 
death,  benefits  are  derived  from  all,  as  brought  out 
in  an  investigation  of  health  conditions  in  Ohio :  ^ 

Many  of  the  miners,  perhaps  the  foreigners  more  than 
olhers,  carried  sickness  insurance  in  several  organizations, 
so  that  the  statement  was  frequently  made  that  a  man 
while  sick  might  draw  more  money  in  sick  benefits  collected 
than  he  did  while  well  and  at  work. 

Conditions  similar  to  this  were  found  by  this  study  in  the 
mining  regions  of  northern  Minnesota  and  Michigan. 
•Societies  differ  considerably  according  to  the  races 
represented  in  the  membership.  Only  the  church 
and  the  small  local  organizations  will  be  considered  in 
examining  these  racial  differences.  The  Poles,  Ital- 
ians, Jews,  and  Greeks  offer  the  most  interesting  varia- 
tions. Much  of  the  data  on  the  Poles  and  Italians 
was  secured  by  interviews  with  families  in  one  of  our 
large  Eastern  cities.  Many  of  these  families  could 
not  speak  English.  More  than  fifty-five  Polish  and 
about  forty  Italian  families  were  visited  and  a  chat  of 
an  hour  or  so  held  with  each.  These  interviews  have 
given  some  interesting  sidelights  on  societies  which 
could  hardly  have  been  secured  in  any  other  way. 

CHURCH,  KEYSTONE  OF  POLISH  SOCIETIES 

Among  the  Poles  it  was  estimated  that  70  to  80  per 
cent  of  the  men  belonged  to  at  least  one  society,  and 

'"The  Health  of  Ohio  Coal  Miners,"  Ohio  Health  Insurance 
and  Old  Age  Pension  Commission  Report,  1919,  p.  875. 

97 


'  IMMIGRANT  HEALTH  AND  COMMUNITY 

that  50  per  cent  of  the  women  have  organizations  of 
their  own.  Many  of  the  Poles  who  were  not  mem- 
bers of  a  society  in  the  United  States  were  those  who 
considered  their  stay  here  too  transient  to  warrant 
membership. 

An  analysis  of  the  fifty -five  family  interviews 
showed  that  whereas  36  per  cent  of  the  men  were 
members  of  church  societies,  only  19  per  cent  of  the 
women  were  so  affiliated.  On  the  other  hand,  the 
tables  were  almost  reversed  on  the  question  of  life- 
insurance  policies  carried  by  commercial  companies — 
the  Metropolitan  and  Prudential  seemed  popular 
among  these  Poles.  Here  36  per  cent  of  the  women 
were  insured,  27  per  cent  of  the  men,  and  48  per  cent 
of  the  children.  This  last  large  figure  is  of  interest 
in  connection  with  the  findings  of  the  Ohio  Health 
Insurance  Commission.  In  reading  the  following  it 
will  be  remembered  that  large  numbers  of  the  coal 
miners  in  Ohio  are  of  Slavic  descent:*  "The  usual 
forms  of  industrial  insurance  were  everywhere  present 
in  the  mining  districts,  through  which  children,  in 
particular,  are  covered  for  funeral  benefits."  The 
charge  for  a  $100  policy  was  usually  10  cents  per 
week  for  a  child,  25  cents  per  week  for  an  adult. 

These  findings  indicate  a  larger  proportion  of  Polish 
wage  earners  helped  by  benefit  societies  than  do 
those  of  the  Pennsylvania  Health  Commission  report 
for  wage  earners  in  general.  The  latter  found  so 
many  restrictions  of  age,  standing  in  the  society, 
kind  of  illness,  that  it  concluded  that  "This  type  of 
health    insurance  .  .  .  reaches    comparatively    few 

*  "The  Health  of  Ohio  Coal  Miners,"  Ohio  Health  Insurance  and 
Old  Age  Pension  Commission  Report,  1919»  p.  S75. 

98 


SELF-HELP  AND  HEALTH 

in  the  wage-earning  group."  The  table  from  the 
IlHnois  Health  Commission's  report,  which  is  quoted 
later,  also  shows  a  much  smaller  proportion  of  each 
race  in  benefit  societies  than  do  the  Ohio  and  Pennsyl- 
vania studies. 

Polish  societies  are  nearly  always  connected  with 
the  Catholic  Church.  They  exist  by  reason  of  close 
proximity  in  the  United  States  of  people  who  speak 
the  same  language  and  have  the  same  ardent  love 
for  the  homeland.  Their  function  is  pre-eminently 
social  and  nationalistic.  Secondarily,  however,  they 
aim  to  aid  members  and  their  families  in  time  of 
illness  or  death. 

The  sick  benefits  paid  by  church  societies  average 
from  $5  to  $7  a  week  for  twelve  weeks.  A  funeral 
benefit  is  always  included.  The  services  of  a  doctor 
appointed  by  the  society  are  usually  available  to 
members  in  time  of  illness,  although  some  societies  pay 
$1  or  $2  a  visit  for  the  member's  own  physician. 
The  men's  dues  vary  from  S5  to  50  cents  a  month, 
depending,  of  course,  on  the  extent  of  sick  and  death 
benefits  offered.  Among  the  women's  societies  the 
dues  range  from  25  to  35  cents  a  month,  and  the  sick 
benefits  rarely  exceed  $5  a  week. 

ITALIANS   FROM   SAME  VILLAGE  UNITE 

Contrasting  in  many  respects  with  these  Polish  so- 
cieties are  the  Italian.  Instead  of  the  church,  the 
keystone  of  their  organization  is  common  origin  in  a 
certain  village  in  Italy,  Many  mutual-aid  societies 
are  continuations  of  similar  organizations  in  Italy, 
where  each  little  town  has  its  own  association  for 

99 


IMMIGRANT  HEALTH  AND  COMMUNITY 

co-operative  undertakings.  In  Genoa,  for  instance, 
there  is  a  socialistic  industrial  society  with  five 
thousand  members  which  is  running  its  own  indus- 
tries. Members  from  this  city  naturally  band  to- 
gether in  the  Unite  States  for  self-aid. 

Thus  it  is  frequently  found  that  the  essential 
requirement  for  membership  in  an  Italian  society 
is  residence  or  birth  in  a  particular  village  or  district 
in  Italy.  As  many  of  these  associations  will  be  found 
in  any  colony  as  there  are  villages  represented.  In 
Boston,  as  already  mentioned,  more  than  one  hundred 
of  these  societies  are  to  be  found,  and  it  is  claimed 
that  there  are  three  hundred  in  Philadelphia.  They 
are  usually  named  after  the  patron  saints  of  the  home 
villages:  "San  Domenico,"  "Santa  Brumitto,"  or 
"Santa  Pepeica."  Women's  societies  are  not  nearly 
so  numerous  as  they  are  among  the  Poles,  and  those 
that  do  exist  are  chiefly  for  intellectual  purposes. 

Among  the  men's  societies,  the  sick  benefits  are 
practically  the  same  in  amount  as  among  the  Poles — 
$6  to  $7  a  week — but  the  period  of  payment  is  a  little 
longer,  thirteen  to  fourteen  weeks.  One  society  was 
found  which  paid  $10  a  week  benefit  for  four  weeks. 
Medical  care  by  the  society  doctor  is  commonly  given 
to  all  members  free,  and  to  their  families  at  one  half 
the  price  usually  charged.  One  society  was  found 
which,  for  an  extra  charge  of  a  dollar  a  year  a  member, 
extends  free  medical  service  to  the  family.  Death 
benefits  of  $50  to  $200  are  universal.  The  monthly 
dues  range  from  60  to  75  cents. 

The  idea  that  a  "society"  exists  to  provide  cash  or 
medical  benefits  is  so  deeply  ingrained  in  the  immi- 
grant's mind  that  he  finds  it  hard  to  understand  or- 

100 


SELF-HELP  AND  HEALTH 

ganization  for  any  other  purpose.  The  following  in- 
cident came  to  light  during  an  interview  with  an 
Italian  family:  • 

Two  years  ago  they  joined  the  Red  Cross  by  pay- 
ing $1  and  were  told  that  whenever  they  needed  help 
to  apply  to  them.  They  did  this  when  the  husband 
was  taken  sick,  but  w^ere  given  no  financial  help. 

Suspicion  and  dislike  of  the  Red  Cross  resulted. 

NATIONALISTIC   INTERESTS   OF  JEWS 

There  is  little  difference  between  the  Italian  societies 
and  those  among  the  Jews.  The  national,  or  Zionist, 
movement  plays  an  important  part  in  the  aims  of 
many  Jewish  organizations,  and  most  of  their  societies 
are  open  to  both  men  and  women.  The  lodges,  how- 
ever, are  large,  as  many  of  them  are  branches  of  state 
and  national  organizations,  and  they  are  based  on 
neither  village  life  nor  the  church. 

In  some,  sick  benefits  are  paid  by  the  central  organi- 
zation out  of  dues  paid  into  the  central  treasury  by 
each  local.  The  dues  commonly  required  to  give  the 
$6  or  $7  a  week  sick  benefit  and  medical  care  for  mem- 
bers are  $1.25  a  month  for  single  men  and  $1.55  for 
married.  Membership  in  the  benefit  systems  is  left 
to  choice  except  in  a  few  organizations.  Most  people 
belong  to  the  societies,  however,  for  the  sake  of  the 
benefits  attached. 

HOSPITAL  CARE   AMONG  THE   GREEKS 

The  Greek  societies  are  formed  almost  entirely  of 
men,  and  they,  like  the  Italians,  base  their  member- 
8  101 


IMMIGRANT  HEALTH  AND  COMMUNITY 

ships  on  former  village  connections  in  Greece.  Ac- 
cording to  a  Greek  physician  interviewed  in  a  me- 
tropolis of  the  East: 

There  are  more  organizations  than  anything  else  among  the 
Greeks.  Every  group  of  ten  to  twelve  people  from  the 
same  vUlage  start  a  society  here,  as  a  branch  of  a  society 
there  or  as  a  matter  of  patriotism.  Their  principal  object 
is  to  raise  money  to  send  home  for  some  public  improve- 
ment: a  school,  a  church,  or  some  undertaking  by  the 
society  in  Greece. 

Comparatively  few  of  these  have  sick  or  death  bene- 
fits attached.  Those  that  have  benefits  make  an  in- 
teresting contrast  with  the  racial  societies  already 
considered.  Hospital  care  is  practically  ignored  among 
the  Poles,  Italians,  and  Jews.  Greek  societies,  how- 
ever, employ  a  doctor  on  contract,  who  cares  for  ill 
members  in  some  hospital  where  expenses  are  paid 
by  the  society.  This  frequent  use  of  the  hospital  by 
the  Greeks  is  a  significant  thing  when  taken  in  con- 
nection with  the  communal  fashion  in  which  the  men 
of  the  Greek  immigration  live.  It  would  seem  to  be 
a  direct  outgrowth  of  the  inadequate  facilities  for 
nursing  afforded  by  the  communal  boarding  house. 


FIRM   FINANCIAL   BASIS   OF   THE   PORTUGUESE 

Among  the  Portuguese  and  Czecho-Slovaks  the  dues 
and  benefits,  both  for  sickness  and  death,  seem  to  be 
somewhat  higher  than  among  other  races.  For  in- 
stance, in  one  Portuguese  society  in  California  the 
dues  were  found  to  be  $26.50  a  year,  while  the  sick 
benefits  varied  from  $5  to  $15  a  week.     Says  one 

doctor  on  that  coast: 

102 


SELF-HELP  AND  HEAXTH 

Due  to  this  high  premium,  the  societies  have  a  firm 
financial  basis  and  are  one  of  the  few  examples  of  workers' 
mutuals  which  have  always  been  able  to  meet  their  obliga- 
tions. As  the  worker  usually  belongs  to  a  group  of  lodges, 
they  furnish  quite  an  adequate  sum  in  case  of  his  sickness. 
Membership  is  open  to  all  nationalities,  but,  due  to  the 
difficulty  of  differences  in  language,  it  is  usually  restricted 
in  practice  to  the  people  of  one  nationality. 

Medical  aid  in  time  of  illness  is  not  always  provided 
by  these  Portuguese  societies. 

BENEFIT    SOCIETIES   IN   CHICAGO 

A  number  of  the  points  brought  out  in  the  investiga- 
tions carried  on  by  this  study  are  corroborated  in 
the  study  of  foreign  benefit  societies  in  Chicago  in 
1918  by  Mr.  Horak,  which  is  included  in  the  Illinois 
Health  Insurance  Commission's  report.  In  securing 
his  data,  he  found  the  same  difficulties  in  Chicago 
that  this  study  foimd  in  other  parts  of  the  United 
States.  Mr.  Horak's  report  presents  the  best  picture 
thus  far  published  of  the  sick-benefit  societies  of  any 
American  community.^ 

New  societies  are  all  the  while  being  formed;  many  of 
the  old  ones  disappear  because  of  lack  of  success  in  their 
endeavors  or  because  their  members  affiliate  with  other 
organizations  or  move  away  or  because  these  societies  tend 
strongly  to  become  locals  of  national  fraternal  orders. 
Under  the  circumstances  it  has  been  necessary  to  secure 
the  names  of  independent  societies  from  other  sources — 
priests  and  clergjTnen,  political  leaders,  newspaper  men, 
social  settlements,  saloonkeepers,  undertakers,  and  the 
officers  of  societies  themselves.     As  a  result  of  inquiries 

1  Report  of  the  Health  Insurance  Commission  of  Illinois^  May  1, 
1919,  pp.  523-524. 

103 


IMMIGRANT  HEALTH  AND  COMMUNITY 

at  all  available  sources  the  number  of  independent  foreign 
societies  in  Chicago,  exclusive  of  athletic  clubs,  building 
and  loan  associations,  entertainment  clubs,  and  singing 
societies,  is  estimated  at  about  600.  .  .  .  Some  of  these 
devote  their  attention  to  educational,  political,  or  social 
aflFairs  exclusively.  Others,  and  especially  many  of  those 
among  the  Jews,  are  primarily  charitable  organizations.  .  .  . 
It  is  estimated  that  there  are  something  more  than  300 
independent  foreign  societies  in  Chicago  which  make  more 
or  less  extensive  and  definite  provision  for  meeting  the 
problems  connected  with  sickness,  accident,  and  death. 
The  investigation  has  been  limited  to  these.  Detailed 
information  with  reference  to  the  provision  made  and  its 
administration  has  been  secured  from  161  of  the  313  found. 
In  so  far  as  possible,  those  studied  have  been  selected  so 
as  to  be  typical  with  reference  to  race,  size,  and  nature 
of  the  benefits  provided. 

The  essential  part  of  the  following  table  is  taken 
from  Mr.  Horak's  report.  There  have  been  added 
the  number  of  foreign  born  in  each  of  the  seven 
largest  racial  groups  in  Chicago,  and  the  ratio  of  the 
membership  in  the  societies  listed  to  these  totals. 

In  looking  at  the  estimated  number  of  societies  for 
each  race  we  find  the  largest  number  among  the 
Czecho-Slovaks  and  Italians,  together  representing 
more  than  50  per  cent  of  all  the  societies.  German 
and  Lithuanian  represent  about  a  quarter  of  the  total 
number.  Only  a  certain  proportion  of  the  estimated 
societies  were  studied,  and  the  membership  of  these 
is  listed,  amounting  to  a  total  of  21,024  members  for 
all  races.  The  census  figures  for  1910  for  the  larger 
races  are  listed  as  a  basis  for  showing  the  per  cent  of 
society  membership  in  each  race.  The  highest  per 
cent  of  membership  in  benefit  societies  is  found  for 
the    Greeks,    Magyars,    Italians,    Lithuanians,    and 

104 


SELF-HELP  AND  HEALTH 

TABLE  XIX 

Independent  Foreign  Benefit  Societies  in  Chicago  * 


Total 
Popu- 
lation, 
19102 

0 

a 

S3 
^^ 

S  ^ 
S  " 

0 

0 
z 
0 

h 

Eh  b> 

^§ 

m 
» 

H 

C 

a 

H 

g 

S 

H 
02 

« 
S 

12; 

Number  of  Those  Studied 
Providing  Each  Speci- 
fied Kind  of  Benefit 

0 

Q 

a 

-0 
a 

OS 

"1 

<a  0 
C5-C 

0  u 

'a 
'a 

CO 

0 

"3 

Croatian 

170 
140 
2,872 
2,302 
1,565 
3,569 
801 
1,588 

206 

1,596 

2,810 

100 

2,384 

80 

100 

110 

631 

'4!8 
1.3 

23.2 
7.8 
1.2 
7.8 

2.2 

'2.4: 

5 

1 
90 
44 
14 
80 
14 
30 

2 
6 
3 
1 
11 
1 
3 
2 
6 

3 
1 

57 

18 

9 

33 

4 

8 

2 
6 
2 

1 
7 
1 
2 
1 
6 

3 

1 

40 

17 

8 

25 

3 

8 

2 
5 
. 

6 

1 
2 
1 
2 

1 

1 

39 

12 

3 

16 

2 

5 

2 
3 
1 

1 
1 
1 
3 

3 

1 

14 

14 

6 

28 

2 

7 

2 

4 
1 
1 
6 

1 
2 
1 
1 

1 

2 

Croatian-Czech . 

'  59,354s 

171,681 

6,742 

45,554 

68,771 

20,273 

Czecho-Slovak .  . 

German 

Greek 

""8 

1 
4 

Italian 

11 

Jewish 

Lithuanian 

Lithuanian  and 
PoUsh 

Magyar 

9,507 
126,059 

Pohsh 

Russian 

Scandina'/ian 

Serbian 

99,513 

1 

Slovak 

Slovenian 

Miscellaneous . . . 

Total  number . 

21,024 

313 

161 

125 

97 

94 

9 

19 

Per  Cent 

77.6 

60.2 

58.4 

5.6 

11  8 

^Report  of  the  Health  Insurance  Commission  of  Illinois,  May  1,  1919,  p. 
524,  Table  I. 

2  Thirteenth  Census,  1910,  vol.  J ,  p.  989 — only  for  races  having  over  5,000 
in  Chicago. 

8  Bohemian  and  Slovak. 


Czecho-Slovaks.  The  Jews,  Germans,  Poles,  and 
Scandinavians  are  at  the  low  end  of  the  range.  The 
Poles  have  only  three  benefit  societies  listed;  because 
SO  many  of  the  Polish  societies  are  connected  with 


105 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  church  they  were  not  included  in  Mr.  Horak's 
study. 

BENEFIT   SOCIETIES   TRANSITORY 

The  increase  in  Chicago  of  Greeks,  Hungarians,  and 
Italians  has  been  very  large  in  the  last  three  decades. 
This  table  indicates  that  benefit  societies  exist  among 
the  more  recent  immigrants.  It  is  fair  to  say  that  in 
general  the  races  which  have  been  in  Chicago  longest 
have  the  lowest,  and  the  comparatively  new  races 
the  highest,  representation  in  these  small  independent 
benefit  societies.  This  fact  suggests  that  they  have  a 
transitory  existence  and  serve  a  purpose  in  the  early 
period  of  adjustment  to  this  country. 

Further  evidence  of  the  mortality  of  these  societies 
was  presented  by  Mr.  Horak  in  his  table  of  the 
approximate  dates  when  155  of  them  were  started.^ 

TABLE  XX 

Periods  in  Which  155  Foreign  Benefit  Societies  Were 

Founded 


Before  1890 
1890-1895 . . 
1895-1900 . . 
1900-1905.. 
1905-1910 . . 
1910-1915 . . 
1915.. 


Total. 


13 
5 
17 
27 
33 
41 
19 


155 


Ninety-three  of  the  societies,  or  60  per  cent,  have  been 
founded  since  1905.  Mr.  Horak  says  that  this  recent 
growth  of  the  majority 

1  Report  of  the  Health  Insurance  Commission  of  Illinois,  p.  630. 

106 


SELF-HELP  AND  HEALTH 

.  .  .  does  not  assist  in  determining  how  many  have 
ceased  to  be  independent  foreign  societies  because  they 
decayed  or  died  or  because  they  were  absorbed  by  the 
fraternal  orders.  Under  the  circumstances  one  must  only 
rely  upon  the  personal  knowledge  of  those  informed.  One 
of  these  is  authority  for  the  statement  that  of  125  societies 
in  existence  twenty-five  years  ago  in  a  certain  district  only 
12  remain  to-day. 

Various  causes  make  for  the  short  existence  of  these 
small  local  societies.  It  is  probably  safe  to  say  that 
they  serve  a  considerable  proportion  of  immigrants 
who  have  not  been  long  in  this  country;  but  they  do 
not  exist  as  permanent  health  agencies. 


INADEQUATE   AS   HEALTH   AGENCIES 

Table  XIX  brings  out  the  fact  that  77.6  per  cent  of 
the  societies  studied  paid  death,  and  60.2  per  cent 
funeral,  benefits,  58.4  per  cent  a  sickness  and  accident 
benefit,  and  only  11.8  per  cent  a  medical  benefit. 
The  amount  paid  for  death  benefit  ranged  from  $15 
to  $250,  and  was  of  course  intended  to  meet  the  cost 
of  funeral  expenses,  leaving  nothing  for  the  remaining 
family.  The  sickness  benefits  showed  a  range  similar 
to  that  found  in  other  parts  of  the  country:  the  mini- 
mum was  $2.50  a  week;  the  maximum,  in  only  one 
case,  was  $15;   the  great  majority  were  $5  or  less. 

When  these  amounts,  as  in  most  cases,  must  be 
turned  over  to  the  family  budget,  there  is  little 
chance  that  proper  medical  care  can  be  secured  also. 
This  would  be  insured  only  in  the  few  cases  where  it 
was   specifically   provided   for,    largely    among   the 

Greeks  and  Italians.     Too  often  service  of  this  sort 

107 


IMMIGRANT  HEALTH  AND  COMMUNITY 

is  vitiated  by  the  character  and  extent  of  medical  aid 
provided. 

Testimony  as  to  this  is  plentiful  and  points  all  in 
one  direction.  The  attitude  of  the  members  of  these 
associations  toward  the  physicians  employed  by  them 
under  contract  is  significant.  One  Italian  said  that 
although  his  society  furnishes  a  doctor  free  of  charge 
to  him  and  half  price  to  his  family,  they  never  call 
him — do  not  like  him  at  all.  Said  another,  "My 
husband  belonged  to  two  societies,  but  left  them, 
as  they  were  too  much  camorista — that  is,  too  full  of 
grafters."  In  general  the  society  doctors  are  neither 
highly  respected  nor  are  they  fully  used  by  members. 

Numerous  interviews  with  foreign-born  and  native 
physicians  have  brought  out  richly  the  attitudes  of 
both  the  members  and  the  doctors: 

When  these  organizations  were  first  started  they  were 
of  very  high  type  and  of  great  benefit  to  Hungarians,  but 
they  are  fast  deteriorating.  When  they  were  first  or- 
ganized they  had  as  medical  advisers  very  efficient  men; 
but  now  a  doctor  is  sometimes  not  chosen  because  of  any 
great  skill,  and  a  man  with  good  practice  has  no  time  for 
such  work. 

These  doctors  are  not  chosen  for  any  superiority  in  their 
profession,  but  because  they  are  popular  with  or  related  to 
the  officers  of  the  organization.  As  a  consequence  many 
times  very  inferior  men  hold  these  positions. 

They  seem  to  have  the  idea  that  if  a  doctor  comes  for 
nothing  or  very  little,  he  is  no  good.  They  think  that  any 
good  doctor  charges  large  prices. 

An  Italian  doctor  stated  that  some  of  his  colleagues 

liked  to  have  an  income  assured,  but  "do  not  care  too 

much  about  giving  care." 

108 


SELF-HELP  AND  HEALTH 

They  are  often  retired  doctors  or  doctors  who  have  not 
made  a  success  in  their  practice.  They  are  looked  down 
upon  by  the  other  doctors  in  the  profession. 

Among  the  Jews  the  testimony  is  similar: 

The  people  have  little  respect  for  these  doctors.  They 
are  usually  young  doctors  who  accept  the  position  for  the 
purpose  of  becoming  acquainted  with  the  members  of  the 
community.  I  have  been  asked  several  times  to  accept 
such  a  position,  but  have  always  refused  because  I  felt  that 
the  work  was  degrading.  The  Jews  have  little  esteem 
for  these  doctors.  .  .  .  The  lodge  doctors  are  chiefly  young 
men  just  entering  the  profession  or  else  rather  elderly 
men.  Another  reason  for  this  lack  of  confidence  in  the 
lodge  doctor  is  the  fact  that  he  is  a  "brother"  and  con- 
sequently too  familiar  a  person  to  command  much  respect, 
for  the  Jews  seem  to  admire  aloofness. 

A  Portuguese  doctor  on  the  Pacific  coast  stated 
that  the  societies  there 

.  .  .  had  found  it  impossible  to  get  the  good  doctors 
at  the  prices  they  could  pay.  The  result  has  been  that 
either  they  have  attracted  the  poorer  class  of  doctors  or 
those  who  have  come  recently  to  the  conununity. 

Evidence  of  this  sort  could  be  multiplied  indefinitely. 
Sufficient  has  been  given,  however,  to  indicate  that 
the  medical  service  secured  by  these  societies  is  of  a 
low  grade.  There  are  some  first-class  and  highly  re- 
spected physicians  in  lodge  or  society  practice,  but 
the  great  majority  do  not  fall  into  this  category. 

The  burden  of  the  evidence  presented  in  this  chap- 
ter brings  out  a  number  of  reasons  why  the  small 

local  or  church  benefit  societies  are  very  much  lim- 

109 


IMMIGRANT  HEALTH  AND  COMMUNITY 

ited  as  health  agencies.  So  far  as  can  be  ascertained, 
they  are  of  a  transitory  character,  reaching  a  Hmited 
number  of  immigrants.  The  benefit  too  often  pro- 
vides funeral  flowers  when  it  might  have  gone  for  the 
medical  care  which  would  have  prevented  the  neces- 
sity for  flowers.  When  it  is  designated  for  sickness  it 
too  often  fails  to  gain  its  end,  either  because  it  is 
inadequate  in  amount  or  because  the  type  of  doctor 
provided  is  unacceptable  to  the  patient.  Last  of  all, 
the  small  benefit  societies  are  often  on  an  unsound 
actuarial  basis  and  are  thus  doomed  to  failure  or 
excessive  handicap  in  competition  with  the  larger 
societies  or  commercial  insurance  companies.  From 
these  facts  it  is  apparent  that  they  can  play  no  large 
or  influential  part  in  medical  care  of  the  immigrant. 

ADVANTAGE  IN  FRIENDLY  ASSISTANCE 

If  the  preponderance  of  the  evidence  is  not  in  favor 
of  the  small  benefit  society,  some  of  its  advantages 
must  not  be  overlooked.  Its  required  medical  exami- 
nation often  affords  an  initiation  into  American  health 
practices  and  standards  that  might  not  otherwise  be 
accomplished  for  some  time.  It  certainly  tends  to 
introduce  the  minimum  standard  of  health  and  hy- 
giene which  prevails  in  this  country.  Furthermore, 
it  accustoms  the  newcomer  to  a  voluntary  health- 
insurance  plan.  This  particular  plan  might  prove 
unsound,  but  the  habit  of  depending  on  some  form  of 
insurance  would  be  established. 

In  addition,  it  is  fair  to  assume  that  belonging  to 
a  benefit  society  made  up  of  friends  and  fellow  coun- 
trymen, gives  to  many  of  its  members  a  sense  of 

110 


SELF-HELP  AND  HEALTH 

assurance  and  security  which  the  stranger  too  often 
lacks.  If  the  mutual-benefit  society  can  bridge  the 
first  period  of  uncertainty  and  adjustment  it  will  not 
be  a  wholly  negligible  quantity.  Its  tangible  accom- 
plishments are  not  always  apparent,  but  the  friendly 
offices  it  performs  in  times  of  trouble  have  an  influence 
in  adapting  the  foreign  born  to  American  ways  of 
doing  things. 


VI 

IMMIGRANT    BACKGROUNDS 

Some  health  oflBcers  declare  that  immigrants  love  to 
live  in  dirt.  A  housing  inspector  is  said  once  to  have 
complained  that  immigrants  stored  coal  in  the  bath- 
tubs when  they  happened  to  be  in  a  tenement  with 
"modern  conveniences."  This  story  was  probably 
true  somewhere  and  sometime.  But  it  has  been  told 
many  times  and  almost  everywhere.  Some  health 
workers  say  immigrants  are  suspicious,  set  in  their 
ways,  if  not  stubborn.  Many  declare  them  to  be 
densely  ignorant  of  hygiene  and  unwilling  to  use 
facilities  for  medical  care  or  health  service,  even  when 
such  are  offered. 

Stories  of  this  kind  about  the  immigrant  have  been 
multiplied,  but  after  all  discounts  are  made  there 
remains  a  kernel  of  truth  in  the  complaint  that  the 
immigrant  frequently  increases  the  problem  of  sani- 
tation, that  he  and  his  family  do  not  respond  to  sug- 
gestions so  quickly  or  so  completely  as  the  American 
health  worker  would  like. 

Our  task  is  not  to  distribute  praise  or  blame.  It  is 
to  state  facts,  to  understand  conditions,  and  then 
determine,  if  we  can,  how  conditions  can  be  made 
more  as  we  wish  them.  We  can  hardly  know  condi- 
tions, and  we  can  never  comprehend  the  reasons  for 

them,  unless  we  know  the  immigrants  as  well  as  their 

112 


IMMIGRANT  BACKGROUNDS 

circumstances.  The  beginning  of  such  knowledge  is 
a  familiarity  with  the  characteristics  of  the  chief 
racial  or  national  groups,  and  particularly  the  con- 
ditions to  which  most  of  them  were  accustomed  before 
they  came  to  the  United  States. 

PEASANT    ORIGINS 

The  bulk  of  our  immigrants  from  southern  and 
eastern  Europe,  except  the  Jews,  are  from  agricultural 
districts.  This  includes  the  Italians,  Poles,  Lith- 
uanians, Russians,  Slovaks,  and  Slavic  peoples  from 
southern  Austria  and  around  the  Adriatic  Sea.  The 
European  agriculturalist  does  not  dwell  upon  an 
isolated  farm  like  the  American  farmer.  He  is  a 
peasant,  by  which  we  mean  one  closely  attached  to  the 
soil.  He  lives  in  a  peasant  community,  which  is  a  rather 
compact  village,  surrounded  by  the  fields  to  which  the 
peasants  go  regularly  from  the  villages  to  work. 

There  is  an  active  communal  life.  The  individual 
is  first  and  foremost  a  social  being.  There  is  strong 
emphasis  upon  the  custom  of  conformity  to  the  group 
and  upon  the  habit  of  participation  in  the  group  life. 
This  is  in  strong  contrast  to  the  American  farmer, 
who  was  originally  a  pioneer  and  retains  many  of  his 
early  characteristics.  Even  in  well-settled  sections 
of  this  country  conditions  as  well  as  traditions 
emphasize  the  individual  rather  than  the  group. 

Very  different  are  the  circumstances  of  the  peasant 
in  central  or  southern  Italy,  or  Sicily,  from  which 
most  of  our  two  million  Italian  immigrants  come: 

In  his  home  village  [says  Mr.  Sartorio]  the  Italian  slept 
with  his  family  crowded  in  one  room.    That  did  not  hurt 

113 


IMMIGRANT  HEALTH  AND  COMMUNITY 

him  or  his  family,  for  they  did  not  live  in  the  room,  as  they 
are  compelled  to  do  here  by  the  bitter  climate;  they  just 
slept  there  for  a  few  hom-s.  During  the  short,  cool  Italian 
nights  only  were  they  inside.  Life  was  spent  working, 
eating,  and  resting  in  the  open  air.  The  sturdy  peasant 
in  Italy  ate  the  fruits  of  his  ortOy  drank  the  wine  of  his 
vineyard,  wore  the  wool  of  his  sheep.  No  one  paid  atten- 
tion, except  when  he  went  to  church  on  Sunday,  to  the  way 
in  which  he  was  dressed,  and  he  was  not  very  particular 
how  infrequently  he  shaved.  Early  in  the  morning  he 
called  out  to  his  friends  across  the  street  as  he  went  to  the 
field.  No  one  was  disturbed  by  it.  People  were  up  early 
in  the  village.  He  sang  as  he  crossed  the  village  going 
to  work  and  coming  back;  the  stornello  of  his  friend 
answered  his  song.  He  walked  in  the  middle  of  the  street 
as  everybody  else  did,  and  did  not  spit  on  the  sidewalk, 
for  the  obvious  reason  that  there  was  none.  ^ 

Take  Professor  Fairchild's  description  of  the  life 
which  most  of  our  110,000  Greek  immigrants  left 
behind  them: 

Life  in  Greece  is  essentially  an  outdoor  life.  It  does 
not  take  the  form  of  athletics  to  nearly  the  same  extent 
as  in  England  and  in  America.  ...  But  the  Greek  loves 
to  sit  out  in  the  open  air.  In  fine  weather  the  public 
squares  of  the  cities  are  closely  dotted  with  tables  belong- 
ing to  the  neighboring  coffee  houses.  .  .  .  To-day,  as 
well  as  in  ancient  times,  one  of  the  most  pronounced 
features  of  the  Greek  character  is  a  sectionalism,  a  clan- 
nishness,  an  inability  to  take  the  point  of  view  of  one's 
neighbor,  which  has  extended  beyond  the  tribal  limits  to 
the  domain  of  personal  relations  and  individual  character, 
making  it  very  difficult  for  Greeks  to  unite  in  any  common 
enterprise.^ 

1  Enrico  C.  Sartorio,  Social  and  Religious  Life  of  Italians  in 
America,  p.  20. 

2  Henry  Pratt  Fairchild,  Greek  Immigration  to  the  United  States, 
pp.  10,  36. 

114 


IMMIGRANT  BACKGROUNDS 

The  primitive  character  of  agriculture  among  the 
Polish  peasants  is  illustrated  in  the  following  letters. 
A  Polish  immigrant  had  written  home  from  the 
United  States,  describing  some  American  agricultural 
machinery  which  he  had  purchased.  One  of  his 
family  wrote  in  reply: 

Now  as  to  the  machines  which  you  bought  and  which 
are  so  expensive,  don't  they  know  scythes  and  sickles  there? 
With  these  tools  you  can  do  much  during  the  summer.^ 

A  father,  writing  shortly  after  his  boy's  departure 
for  America,  inquires: 

And  now,  dear  son,  I  ask  you,  where  did  you  put  the 
ax?  Write  where  you  put  it,  so  we  shall  not  have  to  search 
for  it.2 

The  picture  of  that  family  waiting  from  one  to  three 
months  to  be  told  where  the  ax  was,  instead  of  looking 
for  it,  may  well  Hnger  in  the  memory. 
Miss  Balch  says  of  the  Croatians: 

A  Croatian  house  of  the  poorer  sort  is  often  very  pretty, 
with  its  steep  shingled  roof  and  whitewashed  or  stuccoed 
sides.  Frequently  there  is  no  chimney.  ...  In  poorer 
houses  there  may  be  simply  a  fire  of  twigs  and  branches 
on  the  floor  and  a  baby  wrapped  in  rags  lying  in  the  ashes. 
The  family  sleeps  probably  in  one  room,  occasionally  on 
straw  covered  with  the  curious  Croatian  blankets  which 
are  almost  as  shaggy  as  the  original  sheep,  and  woven  in 
bright,  angular  patterns. 

The  windows  are  apt  to  be  small.  We  heard  of  people 
being  burned  up  because  they  could  not  get  out  through 
the  windows  when  the  house  was  on  fire  and  the  doorway 

^Thomas  and  Znaniecki,   The  Polish  Peasant  in  Europe    and 
America,  vol.  i,  p.  368. 
2  Ibid.,  vol.  ii,  p.  50. 

115 


IMMIGRANT  HEALTH  AND  COMMUNITY 

cut  off.  But  this  defect  is  not  confined  to  Croatia.  It  was 
among  the  Slovaks  that  a  priest  told  us  that  he  preached 
against  windows  *'so  small  that  it  made  an  eclipse  of  the 
sun  if  a  hen  flew  in,"  a  figure  of  speech  suggestive  in  more 
ways  than  one.  .  .  . 

The  cattle  are  often  accommodated  under  the  same  roof 
with  the  family,  either  on  the  same  level,  only  separated 
by  a  partition,  or  underneath  in  a  sort  of  basement  stall. ^ 

The  enormous  contrast  between  such  home  condi- 
tions and  the  immigrant's  new  surroundings  in  New 
York,  Chicago,  or  any  other  large  city,  is  obvious. 
The  contrast  with  conditions  in  a  smaller  American 
city  like  Fall  River,  Wilkesbarre,  or  Pueblo  is  hardly 
less  sharp.  Not  all  our  immigrants,  even  in  recent 
years,  are  peasants,  nor  do  all  enter  cities.  The 
great  bulk  of  first  arrivals,  however,  do  go  to  the 
cities.  The  people  they  know  from  their  own  country 
or  their  own  village  live  there,  and  they  follow  the 
trail  of  their  friends. 

One  important  group  from  which  we  draw  immi- 
grants, the  Jews,  has  been  accustomed  for  centuries 
to  city  dwelling  or  at  least  to  occupations  character- 
istic of  urban  life.  Jews,  however,  come  to  America 
from  small  towns  as  well  as  from  large  cities;  Mr. 
Ravage  shows  us  the  contrast  between  New  York 
City  and  the  Rumanian  village  of  his  boyhood.^ 

This  remarkable  country,  so  newly  discovered  for  us, 
was  infinitely  more  wonderful  than  it  had  appeared  from 
first  reports,  and  infinitely  more  puzzling.  ...  It  was  re- 
grettable that  we  had  learned  this  only  after  Couza  had 
gone,  or  we  might  have  asked  him  to  explain  how  it  was 
managed.     We  might  also  have  been  told  in  an  authorita- 

*  Emily  Balch,  Our  Slavic  Fellow  Citizens,  p.  164. 
2  M.  E.  Ravage,  An  American  in  the  Making,  pp.  29-30. 

116 


IMMIGRANT  BACKGROUNDS 

live  way  whether  it  was  true  that  in  New  York  the  rail- 
ways ran  over  the  roofs  of  houses,  that  the  dwellings 
were  so  large  that  one  of  them  was  sufficient  to  house  an 
entire  town  in  Rumania,  that  all  the  food  was  sold  in  sealed 
metal  packages,  that  the  water  came  up  into  people's  homes 
without  having  to  be  carried,  and  that  no  one,  even  a  shoe- 
maker, went  to  the  temple  on  Saturdays  without  wearing 
a  stovepipe  hat. 

The  important  point  for  us  is  to  discover  what  dif- 
ferences between  the  immigrant's  conditions  here  and 
abroad  have  a  real  bearing  upon  his  health  in  this 
country,  and  so  upon  American  policies  and  methods 
of  medical  or  health  work.  Consideration  of  these 
conditions  discloses  seven  points  of  importance. 


PUBLIC  VERSUS  PRIVATE  HEALTH   ADMINISTRATION 

Although  some  continental  countries  have  a  well- 
developed  system  of  public  health  administration  in 
their  cities,  the  people  in  the  villages  do  not  come  in 
contact  with  it.  Hygiene  is  determined  either  by- 
personal  decision  or  by  custom.  The  only  public 
control  in  health  matters  experienced  by  the  peasant 
is  the  regulation  of  matters  of  birth,  sickness,  water 
and  milk  supply,  by  family  or  district  custom. 

"In  the  city,'*  said  the  little  boy  in  the  story,  "you 
get  your  milk  from  a  cart,  but  in  the  country  it  squirts 
from  a  cow."  The  peasant  was  familiar  with  the 
immediate  sources  of  milk  supply  in  cow  or  goat. 
The  sanitary  supervision  and  control  of  the  milk  sup- 
ply thus  remained  with  the  individual  or  the  family 
and  did  not  become  a  matter  of  public  health  ad- 
ministration. Also  the  disposal  of  refuse  was  wholly 
a  family  matter.  Garbage  might  be  fed  to  the  pigs. 
9  117 


IMMIGRANT  HEALTH  AND  COMMUNITY 


IN  EUKOPE  GAKBAGE  AND  WASTE  WERE  BURNED  OR  FED  TO 

THE  ANIMALS 


Refuse  might  be  thrown  out  or  burned.  If,  however, 
he  throws  an  armful  of  rubbish  out  of  the  fourth- 
story  window  of  a  city  tenement  he  is  in  trouble. 

Street-cleaning  departments  in  some  large  cities  have 

118 


IMMIGRANT  BACKGROUNDS 


IN   AMERICA   DISPOSAL    OF   REFUSE   IS  A  PUBLIC    FUNCTION 

spent  thousands  of  dollars  in  posters  and   placards 

to  teach  immigrants  how  to  dispose  of  garbage,  how 

to  use  the  garbage  can,  when  to  put  it  out,  where  it 

will  be  collected,  where  to  keep  it  when  not  by  the 

curbstone. 

119 


IMMIGRANT  HEALTH  AND  COMMUNITY 

When  the  immigrant  is  suddenly  transferred  to  a 
city  in  which  such  matters  as  housing,  water  supply, 
milk  supply,  contagious  disease,  the  disposal  of  gar- 
bage and  refuse  are  dealt  with  at  long  range  by  gov- 
ernment agencies  through  housing  inspectors,  milk 
inspectors,  food  inspectors,  school  nurses,  he  can 
hardly  be  expected  to  understand.  The  change 
would  be  difficult  for  anyone.  When  the  immigrant 
does  not  know  the  language,  when  no  one  explains 
the  contrasts  and  their  meaning,  how  should  he  com- 
prehend them? 

We  must  understand  these  contrasts  if  we  are  to 
appreciate  the  difficulties  faced  by  the  health  officer, 
the  visiting  nurse,  and  the  social  worker  in  dealing 
with  the  health  problems  of  the  immigrants  in  our 
cities.  We  must  also  recognize  the  difficulties  which 
the  immigrant  faces.  Once  we  attain  such  a  double 
understanding  we  can  deal  with  the  problem  of  edu- 
cation in  an  effective  way.  It  is  not  by  antagonism 
nor  by  the  weight  of  the  Big  Stick,  but  by  explanation 
of  whys  and  wherefores  in  terms  he  will  comprehend, 
and  by  enlisting  his  co-operation  and  that  of  leaders 
in  whom  he  has  confidence,  that  we  help  the  immigrant 
to  get  the  knowledge  which  life  in  a  large  city  requires. 

UNFAMILIARITY  WITH   MEDICAL  RESOURCES 

In  many  cases  the  immigrant  comes  from  a  small 
community,  isolated  from  modern  medical  resources, 
to  a  city  which  has  many  more  advantages.  Even  a 
small  American  city  has  more  doctors  in  proportion 
to  population  than  the  place  which  the  average  immi- 
grant left.    In  many  of  the  backward  districts  of  Eu- 

120 


IMMIGRANT  BACKGROUNDS 

rope,  from  which  hundreds  of  thousands  of  our  immi- 
grants have  come,  there  is  only  one  doctor  to  every 
2,000  or  even  5,000  of  the  population,  whereas  in  the 
United  States  as  a  whole  there  is  one  doctor  to  every 
700  persons,  and  even  in  very  small  communities  the 
ratio  is  rarely  less  than  one  to  1,200.^  The  immigrant 
has  not  been  accustomed  to  use  doctors  as  freely  as 
has  the  native  American. 

This  is  also  true  in  the  matter  of  hospital 
service.  To  the  peasant  the  hospital  was  a  distant 
and  unfamiliar  institution.  It  was  the  resort  in  ex- 
treme emergency.  People  who  went  there  generally 
died.  The  immigrant  does  not  consider  that  perhaps 
they  died  because  they  waited  too  long  before  going 
to  the  hospital.  The  visiting-nurse  association,  the 
numerous  societies  for  the  prevention  of  different  dis- 
eases— tuberculosis,  cancer.  Infant  mortality — were 
quite  unknown  to  the  immigrant  at  home. 

NEW  RELATIONS  TO  GOVERNMENT  IN  THIS  COUNTRY 

Certain  groups  of  immigrants  lived  under  oppressive 
governments  before  coming  to  the  United  States. 
The  Poles,  whether  in  Germany,  Austria,  or  Russia, 
were  under  a  government  which  they  felt  was  trying 
to  denationalize  them.  They  bitterly  resented  the 
efforts  of  the  government  to  crush  out  their  mother 
tongue  as  well  as  other  conditions  imposed  upon  them. 
Their  attitude  toward  local  as  well  as  national  gov- 
ernment after  they  come  to  the  United  States  is 

*  According  to  the  1918  American  Medical  Directory  there  were 
about  150,000  physicians  in  the  United  States,  whose  estimated 
population  was  about  105,000,000. 

121 


IMMIGRANT  HEALTH  AND  COMMUNITY 

affected  by  this  previous  experience.  The  Pole  has 
heard  of  America  as  a  land  of  freedom,  and  after  he 
comes  here  he  is  likely  to  note  how  much  less  the 
government  interferes  with  his  daily  concerns  than 
was  usual  in  his  native  land.  Yet  his  attitude  toward 
government  agents,  the  policeman,  or  the  health  in- 
spector, or  the  nurse,  may  be  colored  by  suspicion 
merely  because  of  his  former  attitude  toward  the  gov- 
ernment of  Poland  and  his  incomprehension  of  the 
nature  and  workings  of  this  government. 

The  Slovaks  of  Himgary  had  to  live  under  the  rule 
of  the  Magyars,  and  like  the  Poles  felt  that  an  op- 
pressive hand  was  endeavoring  to  stifle  their  language 
and  culture.  Such,  in  greater  or  less  degree,  was  the 
situation  of  practically  all  the  southern  Slavic  peoples 
of  Austria-Hungary.  In  a  slightly  different  way  the 
oppressive  and  corrupt  government  under  which  the 
Armenians  and  Syrians  lived  in  Turkey  is  likely  to 
determine  their  attitude  toward  government  and  local 
agents  of  government  in  this  country.  The  Jews,  in 
some  instances,  have  emigrated  from  similar  conditions. 

Suspicion  or  undue  and  unthinking  subservience 
is  the  usual  result  of  such  a  previous  experience. 
The  health  officer,  in  his  plans  for  reducing  disease,  or 
the  nurses  or  social  workers  who  enter  the  homes  of 
the  immigrants  without  understanding  their  back- 
grounds, can  hardly  deal  adequately  with  them  and 
their  problems. 

CHANGED  RELATION  BETWEEN  SOCIAL  CLASSES 

Distinctions  between  social  classes  on  the  basis  of 

wealth,  birth,  or  education  are  more  rigid  in  the 

122 


IMMIGRANT  BACKGROUNDS 

countries  from  which  most  of  our  immigrants  have 
come,  than  they  are  in  the  United  States.  A  well- 
trained  American  nurse  once  visited  a  Polish  home 
to  teach  the  mother  something  about  the  care  and 
food  for  her  baby.  She  reported  that  the  mother 
seemed  suspicious  and  unwilling  to  learn.  Later  the 
mother  said,  in  substance,  to  a  Polish-speaking 
visitor : 

I  do  not  know  who  sent  that  woman  to  my  house.  She 
must  be  one  of  the  educated  people  and  she  must  have  done 
something  wrong  or  she  would  not  be  going  around  this 
way  instead  of  living  with  her  own  class  and  taking  life 
easy  as  they  do. 

The  Polish  woman  could  not  understand  social 
class  except  as  a  status  into  which  a  person  was  born, 
or  at  least  in  which  a  person's  position  was  fixed  for 
life.  She  could  not  understand  why  a  woman,  evi- 
dently belonging  to  what  would  be  called  a  superior 
class,  should  spend  her  time  in  the  homes  of  inferiors. 

Generally  speaking,  the  American,  as  such,  has 
prestige  among  immigrants.  A  person  who  looks, 
speaks,  and  acts  like  an  American,  as  the  immigrant 
conceives  an  American  to  be,  will  sometimes  win  his 
way  despite  ignorance  of  the  immigrant's  language. 
On  the  other  hand,  a  person  of  the  same  race  some- 
times fails,  despite  familiarity  with  the  language  and 
national  customs.  The  explanation  is  found  in  the 
peasant's  suspicion  of  social  class. 

These  considerations  help  determine  the  kind  of 
health  worker  who  will  be  most  effective  among  dif- 
ferent groups  of  immigrants.  They  apply  with  much 
more  force  to  certain  groups  of  immigrants  than  to 

123 


IMMIGRANT  HEALTH  AND  COMMUNITY 

others,  notably  to  Poles  and  most  of  the  Slavic  groups, 
somewhat  less  to  the  Italians,  much  less  to  the  Jews. 


TRANSITION  FROM  AGRICULTURE  TO  tE«)USTRY 

Within  a  few  weeks  the  immigrant  workman  may 
pass  from  a  quiet,  agricultural  community  to  the 
roar  and  motion  of  a  steel  mill  or  a  stockyard.  It 
has  been  more  than  once  pointed  out  that  an  eco- 
nomic loss  is  involved  when  a  worker  who  is  skilled 
in  an  intensive,  though  in  some  respects  primitive, 
agriculture,  goes  into  a  factory,  mill,  or  mine,  where 
his  former  experience  counts  as  nothing,  and  where 
he  must  begin  again  as  an  unskilled  laborer. 

From  the  health  standpoint  this  transition  involves 
certain  hazards,  both  of  accident  and  of  illness.  The 
average  peasant  has  been  accustomed  to  slow  motions. 
He  has  dealt  with  materials  and  processes  which  in- 
volved little  risk  of  accident  or  of  disease.  He  has 
not  been  used  to  machinery.  His  new  job  may  neces- 
sitate quick  motions,  there  may  be  poison  in  the 
materials  to  be  handled,  danger  in  the  processes  to 
be  performed.  Recent  writers  on  industrial  medicine 
have  dwelt  upon  these  contrasts.  Let  us  appreciate 
the  suddenness  of  the  transition,  the  lack  of  prepara- 
tion for  it  on  the  part  of  the  immigrant,  and  the  risks 
to  health  which  are  therefore  involved. 

PHYSIOLOGICAL  STRAIN  DUE  TO  CHANGE  IN 
ENVIRONMENT 

The  sudden  changes  and  severe  winters  of  New  Eng- 
land, New  York,  or  Minnesota  are  a  violent  contrast 

124 


IMMIGRANT  BACKGROUNDS 

to  the  warm  climate  of  Sicily.  Italians  who  make 
this  transition  have  a  considerable  readjustment  to 
make.  Races  from  northern  Europe  find  a  less,  but 
still  a  considerable,  change  in  range  of  temperature 
and  humidity. 

Sometimes  change  in  climate  may  be  beneficial. 
People  from  the  North  take  a  trip  to  Florida  in  win- 


THE   IMMIGRANTS  LIVED,  WORKED,   AND   PLAYED    OUT  OP 
DOORS  IN  EUROPE 

ter,  and  people  from  South  Carolina  go  to  Massachu- 
setts during  the  spring.  When,  however,  the  indi- 
vidual makes  the  transition  without  those  comforts 
and  safeguards  enjoyed  by  the  well-to-do  American 
visitor  to  Palm  Beach  or  to  the  North  Shore,  health 
may  suffer  instead  of  being  benefited.  Many  peoples 
from  different  parts  of  Europe  experience  change  in 

125 


IMMIGRANT  HEALTH  AND  COMMUNITY 

climate  upon  coming  to  this  country.  This  is  gener- 
ally accompanied  by  change  from  an  outdoor  to  an 
indoor  life.  Important  changes  in  diet  may  also  be 
caused  by  the  migration.  Altogether,  the  change  in 
climate,  in  food,  and  in  time  spent  out  of  doors  must 
frequently  produce  physiological  stress  upon  the 
individual 

What  the  influence  of  such  stress  may  be  upon 
death  rates,  birth  rates,  and  disease  rates  is  unknown. 
It  is  difficult  to  separate  these  from  other  factors.  It 
has  been  suggested  by  some  writers  that  the  processes 
of  natural  selection  are  accelerated  by  such  a  transi- 
tion, and  that  individuals  not  sufficiently  resistant  to 
the  new  physical  environment  in  this  country  will  be 
more  or  less  rapidly  weeded  out.  Such  a  biological 
process,  if  it  exists,  may  be  far-reaching  in  determin- 
ing the  numbers,  vigor,  and  prosperity  of  the  present 
and  the  next  immigrant  generations. 

UNFAMILIARITY   OF   LANGUAGE 

The  barrier  of  language  between  many  groups  of  im- 
migrants and  the  native-born  American  presents  dif- 
ficulties in  all  social  relations  as  well  as  in  medical 
and  health  work.  Mutual  difficulty  of  comprehension 
is  one  thing.  A  sense  of  isolation  on  the  part  of  the 
immigrant  is  another.  A  sense  of  superiority  on  the 
part  of  the  American  is  still  a  third.  Difference  in 
language  too  easily  emphasizes  all  of  these. 

The  segregation  of  immigrants  of  one  race  in  the 
same  part  of  a  city  or  town,  largely  caused  by  their 
dependence  on  their  mother  tongue,  of  course  accen- 
tuates certain  of  these  difficulties.    The  learning  of 

126 


IMMIGRANT  BACKGROUNDS 

English  is  made  less  easy.  Group  customs  familiar 
abroad  and  fitted  to  conditions  abroad  are  maintained 
or  strengthened  in  the  American  colony,  even  though 
the  conditions  of  American  life  render  such  customs 
unsuitable.  Moreover,  if  he  lives  in  a  "colony**  of 
his  own  people,  the  immigrant  has  less  contact  with 
his  American  environment  and  less  daily  opportunity 
for  learning  about  it.  It  has  already  been  indicated 
that  the  responsibility  for  the  formation  of  immigrant 
colonies  rests  partly  upon  Americans. 

Viewing  the  Old  World  traditions  and  customs,  we 
find  seven  points  of  contrast  with  American  conditions 
that  complicate  the  health  problem.  (1)  Private  regu- 
lation of  health  matters  at  home  ill  prepares  him  to 
co-operate  with  public  health  administration.  (2) 
Previous  isolation  from  medical  resources  prevents 
his  seeking  those  available  in  America.  (3)  Oppres- 
sive government  at  home  has  prejudiced  him  against 
public  authority.  (4)  Rigid  distinctions  between 
social  classes  in  Europe  make  him  suspicious  of 
friendly  help  from  apparent  "superiors."  (5)  Sudden 
transition  from  agricultural  to  industrial  life  involves 
health  hazards,  as  do  (6)  marked  changes  in  climate, 
diet,  and  time  spent  in  the  open  air.  (7)  Ignorance  of 
our  language  fosters  misunderstanding. 

We  have  reviewed  the  contrasts  between  the 
immigrant's  tradition  and  experience  abroad  and  the 
complex  conditions  of  the  United  States.  These  con- 
trasts affect  all  phases  of  life,  industry,  education, 
recreation,  the  home,  and  last  but  not  least,  the 
individual  and  the  public  health.  It  is  essential  that 
native  Americans  understand  these  contrasts.     We 

must  learn  something  about  the  circumstances  from 

127 


IMMIGRANT  HEALTH  AND  COMMUNITY 

which  the  immigrant  has  come,  as  well  as  about  the 
conditions  which  he  faces  here.  We  must  know  the 
backgrounds  and  the  foregrounds,  and  fit  them  to- 
gether to  make  a  complete  picture  of  the  immigrant 
as  a  human  being  and  a  fellow  citizen. 

Knowledge  of  immigrant  heritages  and  of  the 
immigrant's  environment  in  America  is  the  foundation 
for  any  impersonal,  unprejudiced  study  of  the  im- 
migrant and  for  successful  dealing  with  his  problems 
of  health  and  disease.  Neither  a  program  of  health 
nor  a  program  of  Americanization  as  a  whole  can  rest 
securely  upon  any  other  foundation. 


VII 

IMMIGRANT  RESOURCES  FOR  MEDICAL  CARE 

The  immigrant's  usual  background,  habits,  and  living 
conditions  must  be  held  in  mind  when  we  consider  his 
answer  to  the  question,  "What  to  do  when  sick?" 
The  answer  to  this  question  is  serious  enough  for  the 
native-American  wage  earner,  and  yet  the  American 
family  is  likely  to  be  fairly  well  acquainted  with  the 
physicians  and  the  hospitals  of  the  community  and 
probably  knows  at  least  one  physician  in  the  intimate 
relation  of  family  doctor.  The  problem  of  the  Amer- 
ican family  is  not  so  much  imfamiliarity  with  re- 
sources as  financial  limitation. 

With  the  immigrant  it  is  quite  different.  His 
answer  to  the  question,  "What  to  do  when  sick?" 
depends  not  so  much  upon  the  medical  resources 
which  are  available  in  the  community  as  upon  what 
he  knows  about  them. 

The  readiness  with  which  medical  resources  become 
known  to  the  average  immigrant  is  largely  deter- 
mined by  three  factors :  (a)  their  localization;  (6)  their 
advertising;  (c)  their  contacts  with  the  immigrant 
through  people  or  organizations  of  his  own  race. 
These  three  points  should  be  considered  in  all  plans 
to  make  American  medical  resources  more  readily 
available  and  more  thoroughly  utilized  by  the  foreign 

born. 

129 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Resources  for  the  care  of  illness  become  known  in 
somewhat  the  following  order  to  the  average  immi- 
grant coming  from  a  small  community  to  a  city  in  the 
United  States : 

Home  and  Neighborhood 

The  home  remedy  or  "wise"  woman 
The  midwife 
The  drug  store 

Doctors 

The  advertising  doctor,  medical  institute,  or  quack 
The  private  physician 
The  lodge  doctor 

Organized  American  Agencies 
The  nurse 
The  hospital 
The  dispensary 

HOME  AND  NEIGHBORHOOD 

It  seems  the  part  of  wisdom  to  the  immigrant  to  try 
resources  that  are  near  at  hand  and  that  do  not  cost 
much,  before  turning  to  others.  In  minor  illnesses 
the  immigrant,  like  the  native  born,  appeals  to  the 
home  remedy.  Traditionally  potent  herbs  and  con- 
coctions familiar  in  the  home  village  play  a  large  part 
in  the  family  dosing  of  many  immigrant  adults  and 
their  children. 

The  uneducated  mind  of  the  immigrant  turns  also, 
with  a  confidence  at  which  the  sophisticated  American 
can  only  wonder,  to  the  neighbor  or  friend  of  reputed 
wisdom.  The  grandmother  of  one's  own  or  more  often 
of  a  neighbor's  family,  the  witchwoman,  known  in 
the  old  country,  and  now  in  her  little  circle  here,  as 

one  having  power  to  heal  or  to  prevent  healing — 

130 


RESOURCES  FOR  MEDICAL  CARE 

these  have  frequently  been  mentioned  to  visitors 
investigating  the  health  habits  and  resources  of  im- 
migrant families.  The  more  or  less  experienced 
woman  is  put  to  a  specialized  use  in  midwifery.  This 
practice  is  prevalent  among  immigrants  and  requires 
discussion  in  a  later  chapter.  When  a  visiting  nurse 
finds  a  family  curiously  slow  to  respond  to  her  well- 
meant  advice  it  is  probable  that  the  wise  friend  or 
witchwoman  has  already  furnished  them  with  advice 
of  the  opposite  nature. 

THE  DRUG   STORE 

The  local  drug  store,  the  place  where  most  patent 
medicines  are  purchased,  is  an  important  center  of 
medical  advice.  There  are  several  reasons  for  this. 
Usually  the  local  druggist  or  some  one  in  his  employ 
speaks  the  immigrant's  language,  and  if  there  is  a 
large  colony  of  any  one  mother-tongue  group  there  are 
certain  to  be  several  drug  stores  where  the  language  is 
spoken.  The  drug  store  is  localized  and  therefore 
readily  becomes  known  to  the  immigrant.  We  must 
appreciate  also  that  the  pharmacist  is  regarded  by 
many  immigrants  as  a  man  of  learning.  The  drug 
store  is  anxious  to  co-operate  with  the  immigrant  and 
the  immigrant's  local  organizations. 

The  result  is  not  always  what  we  would  wish,  but 
the  drug  store  must  be  reckoned  with.  A  young  phar- 
macist, born  abroad  but  trained  in  America,  told  his 
plans  for  his  first  venture  as  a  druggist: 

*'I  can  speak  Russian,  Polish,  Yiddish,  and  German.  I 
know  that  neighborhood  [in  which  the  drug  store  was  to 
open]  and  the  people  there.    I  just  bought  out  the  old 

131 


IMMIGRANT  HEALTH  AND  COMMUNITY 

man  who  has  been  running  that  store.  He  has  not  made 
good,  but  I  am  sure  I  can.  He  only  speaks  English.  He 
has  had  a  Yiddish-speaking  clerk,  but  the  clerk  was  more 
interested  in  himself  than  in  the  business." 

"Do  you  know  some  doctors  in  the  neighborhood  so 
that  they  will  send  you  their  prescriptions?" 

*'I  know  one  doctor,  but  the  people  will  know  me  better 
than  they  know  the  doctors  before  long." 

Drug  stores  are  important  from  the  medical  stand- 
point because  it  is  to  them  rather  than  to  the  doctor 
that  the  immigrant  first  turns.  New  arrivals  and 
people  who  have  not  had  occasion  to  use  a  doctor 
since  their  arrival  frequently  turn  to  the  druggist 
for  advice  about  doctors.  Local  doctors  are,  there- 
fore, the  friends  of  the  druggist  and  his  store  is  a 
meeting  place  both  for  social  acquaintances  who  chat 
and  for  business  competitors  who  keep  an  eye  on  one 
another. 

An  Italian  store  in  Providence,  a  Greek  in  Lowell, 
a  Finnish  in  Maynard,  a  Hungarian  in  Bridgeport 
all  seem  to  be  rather  effective  health  centers  for  the 
surrounding  colonies  of  their  people.  The  Hungarian 
druggist  here  mentioned  describes  his  business  thus: 

Hungarians  do  not  use  as  many  patent  medicines  as 
Americans.  They  make  more  of  their  own  brews  from 
herbs  in  the  fields  in  Hungary.  Hence  I  carry  a  large 
stock  of  these.  The  Hungarians  use  hardly  any  pills. 
The  medicines  they  use  are  mostly  in  liquid  form.  The 
druggist  will  not  sell  any  poisonous  drugs  whatever  except 
on  doctor's  orders.  This  habit  was  acquired  in  Hungary, 
where  the  law  forbids  such  sales.  Long  before  the  anti- 
narcotic  law  was  passed  he  did  this. 

In  regard  to  suppression  of  the  patent-medicine  evil, 
he  feels  that  only  responsible  and  trained  druggists  should 
be  allowed  to  sell  drugs.     In  Hungary  only  one  drug  store 

132 


RESOURCES  FOR  MEDICAL  C.\RE 

was  licensed  for  every  five  thousand  population.  In  the 
United  States  grocery  and  dry-goods  stores  carry  drugs. 
In  hands  of  the  ignorant  drugs  are  sold  to  the  ignorant. 

For  myself,  I  do  not  care.  But  it  isn't  fair  to  American 
druggists  to  let  these  stores  and  mail-order  houses  sell 
these  things,  and  then  not  be  responsible.  The  druggist 
is  responsible.  Why,  they  sell  paregorics  by  the  bottleful 
and  stomach-trouble  cures !  Maybe  for  an  alkaline  stomach 
they  sell  bicarbonate  of  soda  and  for  an  acid  stomach  some 
acid.  Here  in  this  country  a  druggist  does  everything: 
telephones,  soda  fountains,  information  bureau,  doctor. 
In  Hungary  he  is  a  skilled  pharmacist. 

When  a  woman  comes  to  me  for  something  for  her  child, 
if  she  says,  "Summer  complaint,"  I  tell  her  to  go  to  a 
doctor  right  away.  That  is  too  serious  to  try  anything 
with.  I  usually  refer  such  requests  to  a  doctor,  though  I 
do  prescribe  for  minor  ailments.  People  do  not  like  to 
bother  with  a  doctor.  He  is  a  nuisance.  He  says  not  to 
eat  this  nor  give  the  baby  beans,  or  something  else.  Some 
medicine  which  the  druggist  says  will  cure  you  surely  is  so 
much  simpler. 

In  the  large  cities  the  local  druggist  plays  a  similar 
part  amid  immigrant  colonies,  but  families  do  not 
depend  upon  him  so  heavily  as  in  smaller  places  and 
he  feels  the  competition  of  American  drug  stores  on 
the  main  streets  more  keenly. 


PRIVATE   PHYSICIANS 

The  line  between  legally  recognized  medical  prac- 
tice and  drug-store  practice  in  dealing  with  disease 
is  not  a  sharp  one,  as  the  preceding  quotation  illus- 
trates. The  "drug-store  man"  goes  as  far  as  he  can, 
sometimes  as  far  as  he  dares,  according  to  his  knowl- 
edge and  his  conscience,  in  prescribing  remedies  for 
10  133 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  symptoms  of  which  his  customer  or  "patient** 
tells  him. 

Perhaps  after  home  and  neighborly  resources  the 
advertising  doctor  is  best  known  to  the  immigrant. 
He  may  not  be  localized  in  the  immigrants'  sec- 
tion, but  his  advertisements  reach  them  through 
the  foreign-language  newspapers.  His  methods  and 
advertised  medicines  are  discussed  later  in  this 
report. 

Both  native  and  foreign-born  physicians  carry  on 
reputable  private  practice  in  immigrant  neighbor- 
hoods, and  to  these  the  immigrant  has  reasonably  easy 
access.  One  of  them  may  even  be  retained  by  his 
lodge  to  care  for  sick  members. 

According  to  American  medical  ethics  the  doctor 
does  not  advertise  except  by  a  simple  shingle  outside 
his  office.  So,  except  as  their  offices  are  in  his  neigh- 
borhood, the  immigrant  can  with  difficulty  ascertain 
the  names  of  reputable  native-born  physicians.  Doc- 
tors of  many  foreign  races  follow  their  native  custom 
of  inserting  professional  cards  in  the  newspapers  of 
the  language,  and  this  is  a  substantial  assistance  to  the 
immigrant.  Such  advertising  doctors  are  in  no  sense 
the  notorious  quacks  who  exploit  the  immigrant  so 
extensively. 

Interviews  with  private  physicians,  either  foreign 
born  or  of  foreign  parentage,  whose  practice  was 
largely  among  immigrant  families,  were  obtained  in 
New  York,  Chicago,  and  other  large  cities  to  the 
number  of  more  than  one  hundred  and  fifty.  Inter- 
views were  also  held  with  native  private  physicians 
who    had    special    contact    with    the   foreign    born. 

Studies  of  medical  work  in  rural  districts  and  in 

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RESOURCES  FOR  MEDICAL  CARE 

particular  fields  were  made.  The  first  aim  of  this 
investigation  was  to  discover  how  far  different  im- 
migrant races  develop  their  own  professional  men  and 
to  what  extent  this  has  solved  their  special  health 
problems. 

INADEQUATE  SUPPLY  OF  IMMIGRANT  DOCTORS 

It  was  possible  to  estimate  the  number  of  foreign 
doctors  in  three  ways.  The  American  Medical 
Directory  gives  lists  of  doctors  graduated  from  foreign 
medical  schools,  as  stated  for  each  community.  Lists 
of  doctors  include  those  with  foreign  names.  In- 
terviews were  had  with  at  least  two  leading  doctors 
of  each  nationality  in  each  community.  From  these 
sources  approximate  figures  were  deduced.  There  are 
in  Chicago  not  less  than  300,000  Poles,  with  not  more 
than  100  Polish  doctors.  On  the  other  hand,  the 
Jewish  population  in  Chicago,  which  is  probably 
about  the  same  as  the  Polish,  includes  from  1,200  to 
1,500  doctors.  The  80,000  Lithuanians  are  said  to 
have  12  doctors.  The  Bohemians,  numbering  per- 
haps 100,000,  have  about  40  doctors.  The  Greeks 
have  between  15  and  20  doctors  of  their  own  race, 
for  a  population  of  20,000.  The  Italians  in  a  popula- 
tion of  150,000  have  about  70  doctors. 

The  marked  contrast  between  the  Jews  and  all 
other  groups  is  noticeable.  The  Jews  have  developed 
a  large  number  of  physicians,  who,  however,  do  not 
confine  their  practice  to  Jewish  people.  The  Greeks 
in  Chicago  have  a  larger  number  of  doctors  in  pro- 
portion to  population  than  any  other  group  except 
the  Jews.     The  proportion  of  doctors  in  these  races 

135 


IMMIGRANT  HEALTH  AND  COMMUNITY 

holds  true,  roughly  speaking,  for  other  cities.  The 
proportion  of  Italian  doctors  to  Italian  population  in 
Chicago  (43  per  100,000)  approximates  the  corre- 
sponding figures  for  Boston  (33  for  80,000  or  41  per 
100,000),  and  for  Providence,  Rhode  Island  (27 
doctors  in  estimated  60,000  population,  45  per 
100,000).  The  proportion  of  Polish  doctors  to 
Polish  population  in  both  Boston  and  Chicago  is 
between  25  and  30  per  100,000. 

In  small  communities  there  will  often  be  found  no 
doctors  of  the  race  to  which  a  considerable  number  of 
the  population  belongs.  Maynard,  Massachusetts, 
has  a  population  of  about  2,000  Finns  in  a  total 
population  of  6,000,  yet  not  one  of  the  five  doctors  of 
the  town  is  Finnish.  In  Duluth,  Minnesota,  with  an 
estimated  population  of  about  5,000  Finns,  there  are 
only  2  Finnish  doctors  out  of  109  doctors  of  all 
nationalities.  The  Ohio  Health  Insurance  Com- 
mission reported  that  the  physicians  in  the  mining 
communities  of  Ohio  and  Illinois  are  almost  entirely 
native  born,  despite  a  very  large  number  of  foreign 
born  in  the  population. 

Not  a  few  immigrant  groups  in  large  cities  are  now 
encouraging  their  young  men  to  enter  professions, 
such  as  law  and  medicine,  and  often  assist  them  to 
get  a  start.  A  Polish  physician,  who  occupied  an  im- 
portant hospital  post  in  one  of  our  large  cities,  and 
who  had  been  in  this  country  for  thirty  years,  told 
how  he  had  watched  the  growth  of  Polish  immigration 
and  the  increasing  efforts  in  several  large  centers  of 
Polish  population  to  develop  young  professional  men. 
As  we  see,  the  results  of  these  efforts  are  only  begin- 
ning to  appear.     The  unusually  large  proportion  of 

136 


RESOURCES  FOR  MEDICAL  CARE 

Jewish  physicians  is  perhaps  accounted  for  by  the 
Jewish  aptitude  for  intellectual  work,  the  high  esti- 
mation in  which  the  professional  man  is  held  by  the 
Jewish  people,  and  the  economic  success  and  mutual 
helpfulness  of  the  group. 

We  can  hardly  overestimate  the  contribution  made 
to  American  life  by  those  immigrants  who,  despite 
all  obstacles,  have  won  their  way  to  success  in  a 
profession  which  requires  so  long  a  training  and 
yields  such  slow  financial  returns  as  medicine.  Some 
of  our  foreign-trained  or  foreign-born  physicians 
have  been  notable  leaders  in  the  iVmerican  medical 
profession,  and  many  young  men  of  foreign  parent- 
age are  now  winning  their  way  to  well-deserved  dis- 
tinction. 

On  the  other  hand,  it  must  be  recognized  that  the 
medical  service  for  the  mass  of  immigrants  must  be 
from  average  rather  than  exceptional  men. 

Moreover,  no  immigrant  group,  apparently,  con- 
fines itself,  or  wishes  to  confine  itself,  to  doctors  of 
its  own  race.  This  may  be  partly  for  the  reason 
already  pointed  out,  that  there  are  not  enough  doc- 
tors of  the  recent  immigrant  groups,  except  perhaps 
among  the  Jews,  to  provide  all  the  medical  service 
needed;  but  the  testimony  of  the  Polish,  Italian, 
Russian,  Hungarian,  and  Greek  doctors  is  all  to  the 
effect  that  their  practice  is  among  native  born  as  well 
as  among  people  of  their  own  race.  The  foreign 
doctor  has  the  great  advantage  of  understanding  the 
language  and  customs  of  his  people.  On  the  other 
hand,  the  native-born  doctor  may,  and  often  does, 
carry  prestige  because  he  is  native  born.      Except 

among  the  Jews,  very  few  foreign  doctors  have  been 

137 


IMMIGRANT  HEALTH  AND  COMMUNITY 

found  whose  practice  was  entirely  among  immigrants 
of  one  race. 


DIFFICULTIES    OF    IMMIGRANT    PRACTICE 

Statements  such  as  the  following,  revealing  the  spe- 
cial difficulties  that  medical  care  of  the  foreign  born 
entail,  are  typical  of  interviews  with  doctors  of  sev- 
eral races  widely  scattered  throughout  the  country. 
A  Hungarian  doctor  in  Connecticut  states: 

There  is  no  such  thing  as  a  family  doctor  among  the 
Hungarians.  In  a  case  of  pneumonia  they  might  have 
any  number  of  doctors  even  at  the  time  of  the  crisis.  A 
man  will  say  to  me,  *'We  do  not  want  you  any  more." 
"Why  not?  What  is  the  trouble.?"  I  would  get  the 
answer,  "Oh,  my  wife  she  get  worse.  You  no  good.  We 
get  another  doctor."  At  first  this  discouraged  me,  but 
I  have  gotten  used  to  it  now.  I  have  seen  six  or  seven 
doctors  meet  at  a  bed  unexpectedly. 

A  Polish  doctor  from  Chicago  gives  similar 
testimony : 

Among  the  poorer  people  it  is  common  for  three  or  four 
doctors  to  be  called  in  on  the  same  case.  One  doctor  is 
called,  prescribes,  and  leaves  the  medicine.  After  the 
patient  has  taken  two  or  three  doses  without  noticing 
any  benefit  he  calls  another  doctor  without  telling  the  first. 
A  doctor  who  wishes  to  know  how  a  patient  is  getting 
along  and  makes  a  call  without  being  sent  for  must  do  this 
at  his  own  expense. 

An  Italian  doctor  from  New  York  said: 

Italians  almost  always  call  an  Italian  doctor  because  of 
the  mutual  sympathy  and  common  language.  The  Italians 
are  very  fond  of  their  families  and  will  spend  every  cent 

138 


RESOURCES  FOR  MEDICAL  C.\RE 

to  care  for  a  member  if  ill.  They  are  not  satisfied  with  the 
American  doctors  because  they  make  a  short  visit,  prescribe, 
and  leave.  This  leaves  the  family  in  much  doubt  and 
accounts  somewhat  for  their  calling  in  another  doctor  if 
there  isn't  a  marked  improvement  in  a  few  hours.  The 
Italian  doctors  tell  the  family  what  the  malady  is,  and 
explain  to  them  all  about  it,  and  this  is  what  they  expect. 
But  the  Italians  are  very  excitable  and  when  a  child  gets 
sick  they  run  off  for  the  nearest  doctor,  regardless  of 
nationality.  They  always  pay  cash  and  as  a  consequence 
they  are  inclined  to  call  various  doctors  at  different  ill- 
nesses, just  as  they  patronize  different  stores.  Most  of 
the  Italians  in  this  section  are  from  the  north  of  Italy  and 
many  of  them  knew  one  another  in  the  old  country.  I 
was  known  in  Europe  by  most  of  these  people,  and  when 
I  came  to  New  York  I  had  a  big  practice  almost  immediately. 

From  these  instances  it  is  evident  that  the  problem 
is  not  merely  to  cure  the  patient.  It  is  to  make  him 
and  his  family  believe  that  he  is  cured  or  is  going  to 
be  cured.  Furthermore,  the  doctor  has  to  compete 
with  other  resources  for  curing  disease — the  drug 
store,  the  quack,  the  wise  woman,  the  hospital,  and 
the  dispensary.  Often  he  needs  to  be  a  psychologist 
and  a  financier  as  well  as  a  medical  man,  if  he  is  to 
cure,  convince,  and  make  a  living  at  the  same  time. 

To  make  a  financial  success  of  practice  among  the 

foreign  born  a  man  must  work  hard.     His  fees  are 

not  large  compared  with  those  charged  by  physicians 

and  surgeons  among  the  well-to-do.    He  is  a  general 

practitioner  and  he  can  derive  relatively  little  income 

from  surgical  operations.    In  order  to  attend  enough 

cases  to  make  a  living  he  must  hurry  through  them 

all.    If  he  has  not  enough  cases  to  keep  him  busy  he 

must  nevertheless  act  as  if  he  were  busy,  lest  his 

prestige  be  diminished. 

139 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Careful  medical  work  generally  calls  for  a  thorough 
physical  examination  of  each  patient;  some  history 
of  the  patient's  disease,  previous  illnesses,  and  family 
health;  a  stethoscope  should  certainly  be  used  in 
examination ;  and  some  laboratory  tests  ought  almost 
always  to  be  made.  As  a  matter  of  fact,  such  physi- 
cal examinations,  history- taking,  and  laboratory  tests 
are  almost  unknown  in  this  class  of  medical  practice. 
If  the  doctor  is  trained  to  such  procedures — which  is 
not  always  the  case — he  has  not  time,  or  he  fears  the 
patient  will  not  understand,  or  would  be  unwilling  to 
submit.  Also,  the  doctor  must  work  with  poor  equip- 
ment. Some  of  these  physicians  can  afford  a  micro- 
scope, and  a  few  appear  to  have  one.  They  are 
called  upon  to  treat  all  kinds  of  disease,  but  their 
equipment  of  instruments  and  appliances  for  diag- 
nosis and  for  treatment  is  usually  very  limited  com- 
pared to  that  provided  in  a  well-equipped  hospital 
or  dispensary  or  in  the  private  office  of  a  physician 
in  good  circumstances. 

These  limitations  are  not,  as  a  rule,  the  fault  of  the 
individual  physician.  In  some  eases  they  are  due  to 
inadequate  training  at  the  low-grade  medical  schools 
formerly  tolerated  in  this  country.  In  many  in- 
stances, however,  they  simply  result,  first,  from 
financial  inability  to  provide  more  than  a  low  mini- 
mum of  professional  equipment,  and,  second,  from 
lack  of  time  or  opportunity  to  utilize  fully  the  knowl- 
edge and  facilities  which  the  physician  does  possess. 
Laboratory  tests  (except  those  provided  by  health 
departments  for  contagious  diseases)  are  practically 
beyond  the  reach  of  the  average  foreign-born  patient. 
The  fees  charged  by  private  laboratories  are  often 

140 


RESOURCES  FOR  MEDICAL  CARE 

more  than  the  fee  the  doctor  himself  would  get  for 
an  ordinary  visit. 

The  physician  practicing  among  the  foreign  born 
rarely  has  a  position  in  a  hospital  or  dispensary.  In 
New  York  City,  where  hospitals  and  dispensaries 
have  been  developed  as  fully  or  more  fully  than  any- 
where else  in  this  country,  an  investigation  made  by 
Dr.  E.  H.  Lewinski-Corwin  showed  that  51  per  cent 
of  the  registered  physicians  had  no  connection  with 
either.  In  communities  where  hospital  and  dis- 
pensary service  are  less  developed  than  in  New  York 
the  proportion  is  undoubtedly  smaller.  The  50  per 
cent  or  more  of  the  medical  profession  who  have  no 
institutional  connection  includes  most  of  the  men  in 
general  practice  in  the  poorer  sections  of  the  com- 
munity, and  so  those  who  serve  the  foreign  born. 

Lack  of  time  and  lack  of  training  on  the  doctor's 
part  are  more  responsible  for  this  deprivation  than 
prejudice  on  the  part  of  the  hospitals  and  dispen- 
saries, although  the  latter  is  not  infrequently  a 
factor.  The  private  physician  fears  that  he  may  lose 
his  patients  and  he  avoids  the  use  of  hospitals  and 
more  particularly  of  dispensaries,  through  which  free 
consultation  with  a  specialist  might  be  had  for  his 
patient. 

Let  it  not  be  thought  that  this  review  of  medical 

practice   among   the  foreign   born  has   ignored   the 

devoted,  efficient,  and  unselfish  service  rendered  by 

innumerable  physicians,  often  when  struggling  under 

very    difficult    conditions.     It    would    be    easy    to 

multiply  such  examples,  and  to  illustrate  the  splendid 

ideals    of    the    medical   profession    and    their   finely 

developed  application  by  men  of  all  races  working 

141 


IMMIGRANT  HEALTH  AND  COMMUNITY 

among  both  rich  and  poor.  But  our  part  has  been 
to  indicate  some  Hmitations  and  problems  of  medical 
practice  among  the  foreign  born  in  order  to  aid,  if 
possible,  the  fuller  realization  of  these  ideals  and  their 
application  on  a  more  inclusive  scale  of  community 
service. 

More  remote  than  the  home  and  neighborhood 
resource,  the  midwife,  and  the  doctor,  legitimate  or 
quack,  is  the  distinctively  American  health  agency. 
The  nurse,  the  hospital,  the  dispensary,  and  other 
forms  of  organized  health  service  are  usually  un- 
familiar to  the  newly  arrived  immigrant.  He  is  not 
accustomed  to  turn  automatically  to  any  of  them. 
If  they  are  to  be  successful  in  their  work,  ways  must 
be  worked  out  whereby  they  meet  him  more  than 
halfway.  How  to  achieve  this  will  be  discussed  after 
we  have  taken  up  more  fully  some  immigrant  health 
customs  which  present  special  difficulties. 


Part  III 
SPECIAL  IMMIGRANT  PROBLEMS 


VIII 

THE   MEDICAL   QUACK 

When  the  immigrant  falls  seriously  sick  the  first  hope 
of  a  cure  is  apt  to  come  to  him  through  the  promises 
of  a  medical  quack.  This  would-be  friend  reaches 
the  immigrant  in  his  home  through  the  foreign- 
language  paper  and,  like  most  things  in  this  new  land, 
is  taken  on  faith. 

In  nearly  all  foreign-language  newspapers  medical 
advertisements  appear.  A  few  of  them  are  the 
legitimate  professional  business  cards  of  ethical 
foreign-born  doctors,  announcing  their  presence  to 
people  of  their  own  race.  Most  of  them,  however, 
are  inserted  by  quack  doctors,  quack  companies, 
chemical  companies  or  laboratories,  for  a  purely  com- 
mercial purpose,  which  is  to  amass  fortunes  by  cheat- 
ing the  immigrant. 

To  be  sure,  "  quackery  and  the  love  of  being  quacked 
are  in  human  nature  as  weeds  are  in  our  own 
fields,'*  and  quacks  conduct  a  certain  amount  of 
business  among  our  native-born  and  English-speaking 
people.  But  their  activities  among  native  born  have 
been  checked  somewhat  by  exposure  of  their  methods 
in  certain  papers  and  magazines,  and  they  have 
turned  their  attention  to  the  fertile  field  of  our 
immigrant  population.  Quack  advertising  in  Amer- 
ican newspapers  has  decreased,  while  in  the  foreign- 

145 


IMMIGRANT  HEALTH  AND  COMMUNITY 

language  newspapers  it  has  enormously  increased, 
during  the  past  five  years.  Let  us  remember  that  to 
the  immigrant  newspapers  are  to  some  extent  organs 
of  authority  as  they  are  not  to  the  native  born. 
Abroad,  it  is  not  so  easy  for  private  individuals  to 
perpetrate  frauds  upon  fellow  citizens  through  the 
medium  of  the  press.  A  Russian  doctor  in  Chicago 
writes :  ^ 

Foreigners,  as  a  rule,  do  not  differentiate  between  the 
regular  physician  (in  America)  who  does  not  advertise  and 
the  advertising  quack.  Quite  the  opposite;  they  look 
upon  the  advertising  charlatans  with  considerably  greater 
respect  than  upon  the  regular  physician,  as  in  their  childish 
simplicity  they  look  upon  everything  printed  in  the  news- 
papers as  absolute  truth.  They  do  not  understand  even 
that  an  advertisement  is  written  and  paid  for  by  the 
advertiser,  and  innocently  think  it  is  the  newspaper  that 
praises  those  physicians  because  they  are  so  good. 

If  the  immigrants  could  follow  in  imagination  the 
stream  of  their  money  as  it  flows  past  the  newspaper 
publishers,  past  the  men  who  furnish  the  drugs,  past 
the  quacks  themselves  in  their  comfortable  auto- 
mobiles and  mansions,  seeing  them  all  grow  rich  as 
they  grow  poor,  they  would  read  with  harder  hearts 
and  more  active  brains  the  glowing  promises  of  the 
"doctors." 

We  must  inquire  what  really  happens  when  the 
sick  or  ailing  immigrant  reads  in  his  own  language, 
in  the  newspaper  of  his  own  people,  in  his  adopted 
land  (remember  it  is  the  promised  land  of  his  ideals), 
the  advertisement  of  the  quack.     How  much  is  he 

1  Henry  R.  Krasnow,  M.D.,  The  Foreigner  a  Prey  of  Medical 
Quacks,  Illinois  Medical  Journal,  32:  342  Nov.  1917. 

146 


THE  MEDICAL  QUACK 

helped  or  injured,  how  much  is  he  doped  and  bled  by 
the  quack  doctor,  the  fraud  office,  the  worthless  or 
harmful  nostrum  bought  at  the  drug  store  or  ordered 
by  mail? 

UNSCRUPULOUS   METHODS 

Twelve  hundred  and  thirty-three  of  the  newspapers 
published  in  the  United  States  are  printed  in  some 
language  other  than  English.  Think  of  it!  In  1828 
only  eight  hundred  newspapers  all  counted  were  pub- 
lished in  our  country.  And  now  the  American 
foreign-language  press  is  half  again  as  great  in 
numbers  and  probably  has  as  many  readers  as  there 
were  then  people  in  the  whole  United  States. 

In  August,  1918,  we  wrote  to  about  a  hundred 
foreign-language  newspapers  asking:  (1)  for  copies 
of  their  latest  issues,  (2)  for  their  advertising  rates  for 
medical  advertisements,  and  (3)  whether  they  pub- 
lished an  almanac  or  calendar.  The  price  of  the 
papers  was  inclosed. 

Most  of  the  newspapers  sent  the  desired  copies, 
and  a  few  other  foreign-language  papers  were  bought, 
adding  to  the  number  examined.  About  twenty-six 
returned  advertising  rates.  A  few  replied  that  they 
published  no  medical  advertisements.  One  publisher 
asked  to  see  copy  before  quoting  prices,  as  he  did 
not  accept  all  medical  advertisements.  Eight  al- 
manacs and  calendars  were  secured. 

All  the  medical  advertisements  were  clipped  from 
these  foreign-language  newspapers.  They  amounted 
to  over  seven  hundred  and  were  printed  in  eighteen 
languages.  This  is  a  cross  section  of  the  medical 
advertisements  in  more  than  one  hundred  leading 

147 


IMMIGRANT  HEALTH  AND  COMMUNITY 

foreign-language  newspapers  at  an  arbitrarily  selected 
moment  during  the  summer  of  1918.  The  advertise- 
ments are  varied  in  form.  Some  are  short  and  matter- 
of-fact;  some  are  long,  but  easy  reading  for  an  un- 
suspecting person;  some  are  in  display  type;  some 
have  a  supposed  portrait  of  the  famous  doctor 
advertiser;  some  are  cleverly  illustrated  in  other 
ways.  Almost  all  have  one  characteristic  in  common 
— a  claim  of  superhuman  power  over  human  disease. 
In  many  cases  a  cure  is  guaranteed.  More  fre- 
quently a  cure  is  implied  in  such  a  manner  that  the 
ordinary  reader  gets  the  idea  that  it  is  promised. 
But  clever  wording  will  usually  save  the  wicked  ad- 
vertiser from  legal  punishment  and  leaves  the  patient 
a  helpless  victim. 

The  field  covered  by  these  quacks  is  almost  as 
extensive  as  the  medical  dictionary.  A  list  of  one 
hundred  and  fifty  different  disorders  or  diseases  was 
made  from  a  few  of  the  advertisements  that  were 
translated,  and  this  could  have  been  greatly  ex- 
tended. We  learn  that  if  we  do  what  we  are  told 
we  will  be  cured  of  asthma  or  anaemia;  backache  or 
bad  luck;  colds,  cancer,  constipation,  or  catarrh; 
dyspepsia  or  drunkenness;  eczema  or  ear  trouble; 
fistula  or  fatigue;  gout  or  general  weakness;  head- 
aches or  hernia;  indigestion,  infectious  diseases,  or 
impurity  of  the  blood;  liver  complaint,  lung  trouble, 
or  "any  long-lasting  chronic  disease";  nervousness  or 
night  emissions;  overwork;  "special  acute  troubles," 
"special  chronic  troubles";  just  "troubles,"  "too 
much  food,"  teething,  trachoma,  tape  worm;  vertigo 
or  yellow  fever.     Of  course  syphilis  and  gonorrhoea 

appear  with  great  frequency,  usually  under  one  or 

148 


THE  MEDICAL  QUACK 

more  of  their  numerous  camouflages;  and  so  do  fe- 
male disorders,  such  as  dysmenorrhoea,  infertility,  or 
too  frequent  fertility. 

Further  analyzing  these  advertisements,  we  found 
232  different  medical  advertisers.  Seventy-one  of 
these  inserted  merely  a  doctor's  business  card,  which, 
according  to  European  custom,  is  perfectly  proper. 
Of  the  232,  156  advertised  once,  32  twice,  and  43 
three  or  more  times.  Of  the  44  men  or  companies 
whose  advertisements  were  foimd  three  or  more  times 
in  our  cross-section  study: 

19  advertised  3  times  2  advertised    9  times 


8 

<( 

4 

2 

(< 

5 

3 

(t 

6 

2 

i« 

7 

2 

<( 

10 

4 

(< 

12 

1 

<< 

17 

1 

t( 

19 

The  amount  of  this  advertising  shows  the  scope  of 
the  business.  It  is  no  small  or  insecure  concern  that 
carries  advertisements  in  a  number  of  papers  simul- 
taneously or  in  several  languages. 

The  160  nonethical  advertisers  were  operating 
from  55  different  cities  and  towns  located  in  18  dif- 
ferent states,  and  in  one  city  of  Canada.  The  part 
of  the  country  covered  stretches  from  New  England 
to  Washington,  D.  C,  and  westward  to  California. 
None  east  of  the  Mississippi  were  located  south  of 
Washington.  W^e  are  not  justified,  by  this,  in  think- 
ing that  our  South  is  free  from  quacks,  but  rather 
that  there  are  not  many  foreign  born  and  foreign- 
language  papers  there.  Certain  business  locations 
appeared  to  be  profitable:  New  York  City  held  73 
of  all  the  advertisers;  Boston,  25;  Chicago,  23; 
Pittsburgh,  15;  San  Francisco,  12;  and  Detroit,  9. 
11  1^9 


IMMIGRANT  HEALTH  AND  COMMUNITY 


The  nationalities  represented  in  the  study  were 
eighteen  in  number: 


Arabic 

Armenian 

Bohemian 

Croatian 

Finnish 

French 


German 

Greek 

Hungarian 

Italian 

Lithuanian 

Norwegian 


Polish 

Portuguese 

Russian 

Slovak 

Swedish 

Yiddish 


There  is  some  ground  for  believing  that  the  newer 
immigrants  more  easily  fall  prey  to  the  wiles  of  the 
quack.  This  surmise  was  strengthened  when  104 
advertisements  were  carefully  translated  and  char- 
acterized by  race. 

TABLE  XXI 

Number   and    Characterization   of   Quack   Advertisements 
Translated  from  Foreign-language  Newspapers 


Language 

Number 

Characterization 

French 

Swedish 

German 

Italian 

Croatian 

Greek 

Hungarian. .  . 

Polish 

Yiddish 

Russian 

Finnish 

3 

2 
22 

29 
4 
3 

23 

7 
2 
3 
6 

Rather  brief;  not  very  glaring. 

Rather  mild. 

About  half  brief;  none  lurid.  Over  half  of 
the  German  advertisers  confine  them- 
selves to  German-language  newspapers. 

All  sorts;  brief,  lengthy,  extravagant. 

Not  lurid,  but  cei;tainly  appealing. 

Most  of  them  long  and  extravagant. 

All  rather  long,  and  designed  to  scare. 

Not  very  long;  sometimes  coarse. 

Extravagant  offers. 

Appealing  to  simple  type  of  mind. 

Uncharacterized. 

104 

From  this  it  would  seem  that  the  French,  Swedes, 
and  Germans  do  not  favor  the  most  lurid  advertisers. 
The  Germans  are  unique  in  that  more  than  half  of 
the  advertisers  among  them  do  not  advertise  in  other 


150 


THE  MEDICAL  QUACK 

languages.  In  all,  there  were  147  advertisements  in 
the  Italian  language,  more  than  in  any  other.  They 
include  all  sorts,  brief  and  lengthy,  mild  and  lurid. 
The  Greek,  Hungarian,  Polish,  Russian,  and  Yiddish 
groups  supply  many  examples  of  the  long,  extrava- 
gant, lurid  advertisement.  It  is  well  to  mention  that 
although  the  Greeks  seem  to  belong  to  this  group, 
two  Greek  papers,  the  Star  and  the  Atlantis y  are 
among  the  very  few  foreign-language  newspapers  to 
refuse  all  fake  medical  advertisements. 

In  order  to  ascertain  what  some  of  these  quacks 
did,  as  well  as  what  they  said  in  the  newspapers, 
letters  were  written  to  fifty-one  different  advertisers, 
as  if  in  response  to  their  advertisement.  These  let- 
ters were  written  in  Italian,  Polish,  German,  and 
English,  most  of  them  under  assumed  names. 

We  had  prompt  replies  from  thirty-four.  Usually 
the  reply  was  a  typewritten  form  letter,  sometimes 
inclosing  a  questionnaire,  testimonials,  and  an  ad- 
dressed return  envelope.  In  one  case  (Health  Spe- 
cialist Sproule)  a  stamped,  addressed  envelope  was 
inclosed.  From  one  ("Apothecary")  a  postal  card 
quoting  the  price  of  a  medicinal  soap  which  he  had 
advertised  was  the  only  reply.  In  a  few  cases  letters 
like  the  following  were  received. 

San  Francisco,  Nov.  19,  1918. 
DoMENEco  Pace: 

Dear  Sir, — Your  letter  is  at  hand.  Send  me  $10  (ten 
dollars)  now  for  your  medicine  for  your  sickness  and  I 
will  send  it  to  you. 

Yours,  etc., 

J.  F.   Gibbon,  M.D., 

1944   Cal.    Street. 
151 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Now  Doctor  Gibbon's  advertisement  had  promised 
to  cure  a  variety  of  diseases,  and  "Domeneco  Pace," 
in  whose  name  we  had  written,  had  given  no  symp- 
toms. Our  letter  merely  stated  that  he  had  been 
sick  a  long  time,  and  spent  much  money  for  doctors, 
and  wanted  to  know  the  cost  of  a  cure. 

Eight  of  the  thirty-four  advertisers  sent  under 
separate  cover  various  kinds  of  booklets  and  pam- 
phlets. The  most  elaborate  of  these  was  from  Doctor 
Williams's  Cancer  Sanitarium.  It  has  fifty-six  illus- 
trations, many  of  them  horrible  views  of  cancer  of 
various  kinds  and  stages.  Pictures  of  conditions 
before  treatment  are  contrasted  with  the  cured  pa- 
tient after  treatment.  It  is  interesting  to  find  that 
some  quacks  who  advertise  in  three  to  five  different 
languages  in  the  newspapers  send  their  letters  and 
circulars  in  English  only,  or  in  English  and  one  other 
language. 

Two  weeks  after  these  first  replies,  follow-up 
letters  began  to  come.  Sixteen  of  the  thirty-four 
advertisers  sent  these,  varying  in  number  from  one 
to  eight.  More  circulars  came  also.  The  Plapao 
Laborator^^  sent  with  the  follow-up  letters  the 
greatest  amount  of  printed  matter,  including  one 
large  sixteen-page  publication.  The  Disillusionist, 
and  another  large  one  of  eight  pages.  The  Progres- 
sionist. The  Dr.  R.  H.  Kline  Company  sent  the 
greatest  number  of  letters.  One  came  from  them 
each  month.  So  persistent  a  follow-up  system  seems 
remarkable,  in  the  case  of  this  company,  because,  as 
they  tell  us  that  we  can  buy  their  remedies  "at  all 
leading  drug  stores,"  they  do  not  know  whether  we 

are  buying  them  or  not.     A  number  of  these  com- 

152 


THE  MEDICAL  QUACK 

panics  possess  an  elaborate  system,  with  dates, 
numbers,  or  letters  stamped  or  written  on  the  return 
envelopes.  In  this  way  they  can  check  up  the 
result  of  the  original  advertisement. 

Despite  their  personal  wording,  many  of  the  type- 
written letters  are  crude  in  form,  so  that  anyone  with 
the  least  experience  would  know  them  to  be  circu- 
lars. Yet  many  immigrants  have  had  no  such  expe- 
rience at  all  and  are  impressed  by  them  as  personal 
communications.  ^ 

The  quack  has  other  methods  of  advertising  be- 
sides the  newspaper  and  personal  correspondence. 
Circulars,  leaflets,  dodgers,  or  cards  are  often  dis- 
tributed from  house  to  house  through  the  localities 
inhabited  by  immigrants.  Sometimes  the  advertise- 
ment takes  the  form  of  a  convenient  little  note- 
book and  diary,  printed  in  English  and  one  or  two 
other  languages.  There  is  reason  to  believe,  how- 
ever, that  in  recent  years  quacks  have  placed  more 
dependence  on  foreign-language  newspapers  and  less 
upon  the  distribution  of  circulars. 

Another  method  of  getting  the  public  confidence  is 
described  in  a  report  from  the  New  York  State 
Bureau  of  Industries  and  Immigration  (1914):^ 

A  museum  is  fitted  up  in  a  prominent  section  of  the  city 
with  a  gorgeous  display  of  physiological  exhibits.  Upon 
entrance  to  the  lobby,  where  the  exhibits  are  open  and  free 
to  all  men,  you  are  approached  by  a  person  who  gives  you 
literature  which  is  so  framed  as  to  make  one  suspect, 
judging  from  the  symptoms  and  signs  which  are  described 
in  the  circular,  that  one  has  symptoms  of  some  awful 


1  Fourth  Annual  Report,  New  York  State  Bureau  of  Industries 
and  Immigration,  1914,  pp.  257-258. 

153 


IMMIGRANT  HEALTH  AND  COMMUNITY 

plague  and  every  other  conceivable  disease;  thus  is  one 
induced  to  consult  a  specialist  in  charge  of  the  museum, 
who  has  his  office  in  the  building.  .  .  . 

Not  only  are  the  successful  quack  advertisers  clever 
business  men,  they  also  appear  to  be  expert  psycholo- 
gists. They  kpow  how  to  compel  people  to  give 
attention. 

The  medical  advertisements  which  form  the  basis 
of  our  study  range  in  size  from  a  few  lines  to  a  whole 
page.  A  small  proportion  are  short,  almost  as  brief 
as  a  business  card.     The  following  is  an  example: 

Dr.  JOSEPH  BIER 

WOMAN    SPECIALIST 

INTENTOR    OF    LAUDANT    ANTISEPTIC    POWDER 
FOR    WOMEN 

302  West  72d  Street 
Hours  11-1 

On  the  other  hand,  a  medical  advertisement  may  be 
723  words,  filling  a  whole  page  of  147  inches  with 
large  display  type  and  an  illustration.  Such  is  the 
"Partoglory"  advertisement  printed  in  Polish  in  the 
Ameryha-Echo. 

This  advertisement  illustrates  a  showy  and  ex- 
pensive type,  probably  from  a  very  prosperous  com- 
pany. It  is  cleverly  and  attractively  written  by  a 
professional  advertisement  writer.  The  cost  of  one 
insertion  we  estimated  at  $123.48,  according  to  the 
quoted  advertising  rates  of  the  paper.  The  largest 
portion  of  the  advertisement,  like  so  many,  is  given 
over  to  a  discussion  of  current  events,  of  which  the 

following  is  only  a  part: 

154 


THE  MEDICAL  QUACK 

September  9,  1918 

AIMERYKA-ECHO 
(At  left  picture  of  American  soldier) 

The  Allies  Are  Moving  Forward 

The  English  have  taken  Bapaume — Noyon  has  been 
taken  by  the  French.  The  Americans  have  captured 
Juvigny.  After  a  hot  battle,  in  which  all  the  armies  of 
the  Allies  showed  unheard-of  courage  and  bravery,  three 
main  territories  were  taken  from  the  Kaiser.  Our  American 
soldiers  under  the  leadership  of 

General  Pershing 

have  shown  the  enemy  that  they  possess  the  true  spirit 
of  battle.  .  .  .  Until  the  end  we  Poles  are  heart  and  soul 
for  President  Wilson,  with  whose  help  we  have  had  oppor- 
tunity to  regain  Freedom  and  Polish  Territory.  But  at 
the  same  time  we  must  remember  that  our  health  plays 
an  important  part  in  our  lives.  Without  health  nothing 
can  be  reached  and  yet  there  are  a  great  many  people 
among  us  who  disregard  their  health.  .  .  .  Nervousness  is 
an  illness  which  is  spreading  at  the  present  time. 

Because  of  this,  learned  people  are  working  with  energy 
to  find  a  sure  cure  for  nervousness.  After  several  years 
of  study,  practice,  and  knowledge  there  was  discovered 
at  last  a  successful  elixir  for  the  nerves 

Partoglort 

which  is  used  by  thousands  of  people  with  unusual  results. 
Partoglory  was  discovered  by  a  renowned  chemist  and 
pharmacist,  Michael  Partosa  .  .  .  etc. 

The  Inventor  of  Partoglory  invented  also  excellent 
candy,  "Partola,"  which  is  very  efficient  in  all 
troubles  of  the  stomach.  K  your  stomach  is  not  in 
order,  if  you  suffer  from  constipation,  if  you  have  a 
headache,  if  you  suffer  from  lack  of  appetite,  erup- 
tions on  your  face  and  body,  there  is  no  better  medi- 

155 


IMMIGRANT  HEALTH  AND  COMMUNITY 

cine  than  Partosa's  Partola.  Take  three  candies 
before  going  to  bed  and  the  very  next  day  you  will  be 
normal  and  healthy.  Specifications  and  testimonies 
are  contained  in  the  advertisement. 

It  is  common  to  find  an  appeal  on  the  basis  of 
nationality.     The  following  is  typical: 

Dr.  Colhoeur — Successor  to  Dr.  William  Alden 
717  Liberty  Avenue,  Pittsburgh,  Pa. 

Fellow-Citizens:  Look  for  help  there  where  you  can 
find  it,  which  will  bring  you  out  on  the  right  path.  This 
is  the  only  doctor  from  the  old  country.  He  speaks  Russian, 
and  has  a  practice  of  twenty-five  years.  He  cures  with  the 
best  remedies  chronic  and  all  diseases.  Do  not  lose  any 
time.  Come  promptly  to  his  office.  Advice  free.  Visiting 
hours  from  9-8;  Sundays  from  10-1. 

The  immigrant  has  heard  of  Abraham  Lincoln  even 
in  his  far-away  native  land.  A  quotation  from  him 
introduces  an  account  of  Doctor  Liverpool's  con- 
summate skill  in  curing  whatever  is  your  ailment. 
How  splendid  this  doctor  must  be  who  has  ideals 
expressed  by  a  quotation  from  Lincoln!  A  large 
picture  of  the  doctor  heads  his  advertisement. 

So  every  human  emotion  is  appealed  to.  Fear  and 
anxiety  are  played  upon.  "Take  every  cough  seri- 
ously" is  only  slightly  less  ominous  than,  "Blood 
disease  digs  the  graves  of  millions."  Perhaps,  har- 
assed by  economic  pressure,  the  immigrant  is  soothed 
by  "try  it  at  our  expense"  or  "consultation  and 
examination  free."  What  to  a  more  sophisticated 
person  would  seem  incredible,  to  the  bewildered  im- 
migrant spells  a  last  resort.  "I  can  tell  you  im- 
mediately from  what  you   are  suffering  by  simply 

156 


THE  MEDICAL  QUACK 

looking  at  you."  "I  cure  with  success  every  disease." 
The  testimonial  from  some  person  who  claims  to  have 
been  cured  immediately  is  taken  at  its  face  value. 
Such  is  the  unsavory  range  of  advertising  methods 
found  in  all  too  many  foreign-language  newspapers. 

The  letters  as  well  as  the  newspaper  advertisements 
play  upon  fear  of  sickness,  fear  of  operations,  fear  of 
pain,  fear  of  death,  fear  in  women  of  the  dangers  of 
childbirth.     Doctor  Whittier's  letter  says: 

Remember   the   poet  said: 

"Of  all  sad  words  of  tongue  or  pen 
The  saddest  are  these, 
'  It  might  have  been.'  " 

Ah,  the  pathos  of  these  words,  "It  might  have  been!" 
That  is,  it  might  have  been  life  instead  of  death  for  me! 
Remember,  every  day  you  will  get  a  little  worse. 

The  follow-up  letters  from  Doctor  Williams  rise  to 
a  climax.  Each  is  more  frightening  than  the  last. 
The  following  quotations  are  the  key  sentences  to 
three  successive  letters. 

1.  If  there  is  a  cancerous  condition  present,  it  is  danger- 
ous and  should  have  immediate  treatment. 

2.  You  know  that  cancer  grows  worse,  never  better; 
sometimes  slowly,  but  in  the  end  it  always  progresses. 

3.  You  have  a  cancer.  You  know  that  nature  offers 
no  hope  of  a  cure,  and  that  your  days  are  numbered. 

The  Get  Thin  and  Get  Fat  advertisers  play  upon 

our  pride  of  personal  appearance  and  sensitiveness 

to  other  people's  remarks  about  how  we  look.    Thus 

Doctor  Newman  works  to  make  you  thin.     "That 

157 


IMMIGRANT  HEALTH  AND  COMMUNITY 

you  are  too  stout  and  would  like  to  reduce  your 
superfluous  fat  you  know  very  well"  is  as  appealing 
as  "to  live  again  free  from  fat  and  worry."  A  final 
blow  at  the  very  roots  of  individual  pride  is  struck 
in  "You  are  doing  nothing  to  safeguard  your  social 
position.  You  know  that  your  figure  has  lost  the 
graceful  outlines  it  once  had,  that  was  so  pleasing  to 
you  and  to  every  beholder," 

On  the  other  hand,  Viratole  will  make  you  fat. 
No  ingenuity  is  spared  in  seeking  to  arouse  the  slug- 
gish desire  of  the  thin.  "The  thin,  nervous  man  is 
the  one  who  suffers  the  horrors  and  the  humiliation 
of  looking  starved."  "Surely  a  woman  who  has  the 
appearance  of  a  broom  handle  is  far  from  being  a 
pleasing  sight  on  the  street."  Social  pressure  is  again 
applied:  "Many  a  man  is  ashamed  to  go  on  the 
street  with  his  wife  because  she  is  so  thin  looking." 
"On  all  public  jobs  where  many  men  meet  it  is 
always  the  thin  and  sickly-looking  fellow  who  is 
laughed  at,  and  very  often  called  names  which  are 
surely  an  insult  to  his  bad  fortune." 

For  those  of  us  who  are  of  a  sentimental  tempera- 
ment come  messages  sounding  the  praises  of  the 
saintly  advertiser:  "Do  not  lose  faith  in  Humanity. 
Having  the  means  in  our  hands  to  do  so  much  good, 
we  beg  of  you  not  to  think  of  us  as  having  a  soul  so 
small  as  to  put  everything  on  the  dollar  basis."  This 
spirit  of  friendliness  is  no  doubt  acceptable  to  the 
stranger:  "We  have  missed  your  letters  for  some 
time,  and  inasmuch  as  we  are  really  interested  in 
your  welfare  and  sincere  in  our  desires  to  help 
you  .  .  ."  The  pleasant  platitude  may  turn  the 
scales  in  favor  of  the  doctor:   "To  do  a  kindness  for 

158 


THE  MEDICAL  QUACK 

others  is  the  greatest  happiness  one  can  experience." 
If  a  man  is  a  good  patriot  how  impressive  is  the 
photographic  reproduction  of  five  orders  written  upon 
War  Department  paper  to  the  Plapao  Company  for 
their  Adhesive  Pads! 

If  one  is  unable  to  resist  the  marvels  exposed  in 
correspondence  with  the  quack,  there  are  either 
medicines  or  professional  treatment  available.  The 
medicine  may  be  mailed  directly  from  the  factory, 
as  in  the  instance  of  the  Mollinger  Medicine  Company 
or  the  Antonina  De  Anna  Chemical  Company,  or,  as 
in  the  case  of  Nuxated  Iron,  it  may  be  purchased  in 
any  drug  store.  Medicines  are  often  advertised  by 
the  drug-store  men  themselves,  who  build  up  trade 
by  featuring  special  goods.  As  examples  may  be 
mentioned  the  Crown  Pharmacy,  the  Red  Cross 
Pharmacy,  St.  Elizabeth's  Drug  Store,  Niedlich's 
Drug  Store,  and  the  Metropolitan  Drug  Store.  If 
you  are  persuaded  that  professional  treatment  is  the 
only  way  out,  one  group  of  doctors  advertise  office 
hours,  but  will  also  give  home  treatment  or  send 
advice  by  mail,  if  you  so  desire. 

The  largest  class,  and  undoubtedly  the  greatest 
mischief-makers,  are  those  who  advertise  office  treat- 
ment under  the  name  of  a  physician,  a  company,  or 
a  medical  institute.  These  urge  patients  to  come  to 
finely  equipped  offices  or  "private  institutes."  In 
the  advertisement  of  Doctor  Lyons  we  read,  "Con- 
sultation and  complete  examination  free."  This 
complete  examination  extends  even  to  the  clothes, 
the  pocketbook,  and  the  bank  book  of  the  patient. 

While  a  number  of  the  medicines  and  appliances 

were  sent  for  during  this  study,  there  was  no  inves- 

159 


IMMIGRANT  HEALTH  AND  COMMUNITY 

ligation  of  the  medical  institutes  because  a  vivid 
picture  of  their  operations  is  given  in  the  report  ^  of 
an  investigator  for  the  New  York  State  Bureau  of 
Industries  and  Immigration,  prepared  in  1914.  It 
will  be  quoted  only  in  part: 

A  sumptuous  office  is  fitted  up  and  an  imposing  trade 
name  is  adopted.  .  .  . 

The  apphcant  is  ushered  into  a  private  office.  To  comply 
with  the  law,  a  registered  physician,  under  whose  name 
the  institute  operates,  and  who  is  very  often  only  an 
instrument  in  the  employ  of  an  unregistered  financial 
backer,  in  addition  to  two  or  three  interpreters  all  repre- 
senting themselves  as  physicians,  take  the  patient  in  hand. 
He  is  placed  before  a  large  machine  of  complex  appearance 
that  conveys  the  impression  to  the  ignorant  immigrant 
of  being  costly  and  almost  miraculous,  and  is  examined 
by  the  two  or  more  interpreters,  who,  dramatically  and 
with  apparent  emotion,  inform  the  patient  that  he  is  suf- 
fering from  some  dreadful  disease,  which  if  longer  neglected 
will  result  in  death.  The  patient  becomes  alarmed  and 
agrees  to  pay  any  price  for  a  cure,  which  is  guaranteed. 
A  large  amount  is  at  first  requested  as  part  payment,  but 
any  amount  that  the  patient  has  or  can  obtain  is  accepted. 
It  is  unnecessary  to  state  that  the  so-called  examination 
and  the  later  "treatment"  are  absolutely  without  merit 
and  that  unregistered  assistants  are  acting  as  physicians 
and  "treating"  the  patient.  No  prescriptions  are  given, 
as  the  so-called  institutes  provide  and  sell  directly  all 
medicines  and  medicinal  appliances. 

The  following  complaints  are  typical  of  the  nu- 
merous complaints  on  file  with  this  bureau,  and  de- 
scribe the  methods  of  these  so-called  institutes : 

C.  D.,  a  Greek  laborer,  twenty-three  years  of  age,  two 
years  in  United  States,  received  a  circular  in  the  Greek 

^  Fourth  Annual  Report,  New  York  State  Bureau  of  Industries 
and  Immigration,  1914,  pp.  257-258. 

160 


THE  MEDICAL  QUACK 

language,  issued  by  one  of  the  so-called  medical  institutes. 
Feeling  somewhat  ill,  he  called  at  said  institute  for  "free" 
consultation  and  advice.  He  was  examined  and  told  that 
he  was  suffering  from  a  dangerous  disease.  He  was  asked 
to  pay  $7  for  the  examination,  but  only  paid  $2,  all  the 
money  he  had,  and  was  asked  to  sign  an  order  for  $5  more 
on  a  private  bank  where  he  had  $80  on  deposit. 

It  developed  that  the  amount  of  this  order  was  left 
blank  and  subsequently  it  was  made  out  for  $73,  which  the 
physician  withdrew  from  the  bank.  The  patient  soon 
found  out  from  the  private  banker  that  his  bank  balance 
was  $7 — as  all  the  other  money  had  been  withdrawn. 
The  bureau  succeeded  in  obtaining  the  return  of  his  money.^ 

Mrs.  S.  R.  was  also  induced  through  a  circular  she 
received  to  bring  a  child  two  years  old  to  one  of  these 
institutes.  Before  examining  the  child  the  professor  asked 
Mrs.  S.  R.  for  $7,  which  she  paid.  Without  examining  the 
child,  pills  were  prescribed  and  given  for  the  child.  Mrs. 
S.  R.  was  instructed  to  return  with  the  child  in  a  few  days 
with  $19 — the  balance  of  the  fee  required.  The  child, 
unable  to  swallow  pills,  was  taken  to  the  institute  by  the 
mother  the  following  day  and  liquid  medicine  was  now 
given,  but  when  Mrs.  S.  R.  stated  that  she  was  unable  to 
pay  the  balance  of  $19  the  medicine  was  taken  away. 
The  child's  condition  thereafter  became  so  serious  that  it 
was  necessary  to  take  her  to  a  hospital.  Refund  of  the 
money  paid  was  obtained  through  action  by  this  bureau. 

Two  investigators  disguised  as  immigrants  called  at  a 
certain  "institute"  which  had  distributed  circulars  and 
were  examined  by  an  unregistered  "physician,"  who  charged 
$2  for  the  examination.  The  investigators  were  told 
that  one  of  them  was  in  the  last  stage  of  consumption  and 
unless  immediately  treated  would  not  live  longer  than  one 
month.  The  institution  guaranteed  to  cure  for  $50.  The 
investigators,  before  going  to  the  institute,  were  examined 
by  the  department  of  health  physicians,  and  after  leaving 

^  Fourth  Annual  Report,  New  York  State  Bureau  of  Industries  and 
Immigration,  1914,  p.  259. 

161 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  "institute"  by  a  private  physician;  and  they  were 
found  to  be  in  perfect  health.  The  bureau  succeeded  in 
having  all  the  money  collected  from  a  large  number  of 
complainants  returned  to  them  and  the  proprietor  has 
since  discontinued  the  entire  business. 

One  of  these  so-called  professors  who  was  not  a  registered 
physician  confessed  and  disclosed  some  valuable  information 
in  a  statement  to  this  bureau  which  in  part  asserts  that 
before  examination  the  patient  is  asked  to  undress  in  an  ante- 
room and  there  his  clothes  are  searched  for  bank  books, 
money,  etc.,  so  as  to  enable  the  person  examining  him 
to  judge  how  large  a  fee  to  demand.  .  .  .^ 

This  describes  only  some  of  the  more  outstanding 
and  typical  methods  of  the  quack  doctor.  He  uses 
whatever  devious  and  subterranean  means  occur  to 
him  at  the  moment  to  lure  his  victims  on.  How  he 
escapes  from  responsibility  when  he  has  guaranteed 
a  cure  and  failed  to  help — perhaps  even  made  mat- 
ters worse — one  may  conjecture  more  easily  than  de- 
scribe. Often  he  can  put  it  back  upon  the  patient, 
saying  he  has  not  obeyed  orders,  or  has  not  taken 
his  medicine  regularly,  or  has  not  "kept  on  long 
enough."  Doctor  Faker  is  usually  wise  enough  to 
have  a  legal  adviser  who  could  undoubtedly  answer 
the  question  for  us.  A  study  of  his  methods  is  suffi- 
cient to  condemn  him,  however,  and  afford  a  basis 
for  the  discussion  of  how  to  deal  with  him. 

Agencies  and  powers  exist  in  our  society  which 
deal  or  are  capable  of  dealing  with  this  monstrous  evil 
of  the  quack.  His  frauds  have  been  investigated  by 
the  American  Medical  Association  and  exposed  in  the 
American    press.     The    foreign-language    newspaper 

^  Fourth  Annual  Report,  New  York  State  Bureau  of  Industries  and 
Immigration,  1914,  p.  260. 

162 


THE  MEDICAL  QUACK 

has  the  power  to  put  him  out  of  business  by  refusing 
to  print  his  fraudulent  advertisements.  There  is  both 
Federal  and  state  legislation  framed  to  control  his 
activities,  and  certain  health  organizations,  public 
or  private,  seek  to  bring  him  to  justice.  It  is  obvious 
that  these  forces  are  not  yet  sufficiently  developed  to 
meet  the  situation. 


EXPOSURE   THROUGH    PUBLICITY 

In  1905  Mr.  Samuel  Hopkins  Adams  in  Collier^ s 
Weekly  called  the  attention  of  its  readers  to  the 
enormity  of  quack  frauds  in  some  vivid  and  reliable 
articles.  The  Chicago  Tribune  followed  up  the  work 
of  exposure.  Dr.  Harvey  Wiley,  m  popular  writings 
in  Good  Housekeeping  and  elsewhere,  has  made  people 
think  and  question  a  bit  before  buying  cure-alls  and 
wonder  remedies. 

The  American  Medical  Association  has  done  and  is 
doing  valuable  work  in  laboratory  analysis  of  many 
quack  preparations  and  patent  medicines  and  in  the 
publication  of  many  articles  and  pamphlets  on  nos- 
trums and  quackery.  The  following  pamphlets  and 
others  can  be  secured  from  the  American  Medical 
Association  at  535  North  Dearborn  Street,  Chicago: 
"Cancer  Cure  Frauds,'*  "Consumption  Cures,'* 
"Convictions  Under  the  Food  and  Drugs  Act," 
"Epilepsy  Cures,**  "Female  Weakness  Cures,**  "Med- 
ical Institutes,'*  "Men's  Specialists.'* 

These  publications,  however,  reach  few  of  the  laity, 

and  one  might  guess  that  the  average  doctor  is  too 

busy  to  do  much  in  spreading  the  information  that  is 

at  hand.     The  more  popular  articles  in  newspapers 

163 


IMMIGRANT  HEALTH  AND  COMMUNITY 

and  magazines  have  had  some  effect  upon  native 
pubHc  opinion,  but  they  could  not  be  expected  to 
reach  the  great  mass  of  immigrants. 

EESPONSIBILITY     OF     THE     FOREIGN-LANGUAGE     PRESS 

Although  a  certain  amount  of  business  comes  to 
quacks  through  circulars  or  personal  connections, 
newspaper  advertising  supports  the  big  end  of  the 
business.  The  great  majority  of  foreign-language 
newspapers  accept  quack  advertisements  indiscrimi- 
nately, and  to  this  extent  they  are  party  to  their 
frauds. 

An  analysis  of  our  quack  and  patent-medicine 
advertisements  was  made  on  the  basis  of  the  ad- 
vertising rates  sent  by  the  publishers  of  the  papers. 
Sixty-two  papers  sent  us  their  rates.  Of  these,  fifty- 
three  had  medical  advertisements.  The  accompany- 
ing table  gives  in  detail  the  amount  of  space  devoted 
to  medical  advertisements  in  one  issue,  selected  at 
random,  of  each  of  a  number  of  newspapers.  All 
are  from  about  the  same  period  in  1918.  The  es- 
timated income  from  these  advertisements  is  cal- 
culated from  the  rates  as  given,  and  what  per  cent 
it  bears  in  each  paper  to  the  total  advertising  income 
is  estimated  from  the  space  utilized  at  the  various 
rates.  This  showed  that  the  income  to  the  news- 
papers from  medical  advertising  was  usually  a  con- 
siderable percentage  of  their  income  from  their  whole 
advertising.  The  table  also  classifies  the  papers  ac- 
cording to  language.  It  may  be  seen  that  as  a  rule 
the  papers  of  the  nationalities  which  have  arrived 

more  recently  derive  larger  proportions  of  income 

164 


THE  MEDICxVL  QUACK 

from  medical  advertisement.  This  is  not  invariably 
true,  but  the  trend  is  sufficient  to  warrant  the  generali- 
zation that  the  more  helpless  immigrants  are  the 
most  exposed  to  exploitation  of  this  sort. 

TABLE  XXII 

Percentage  op  Advertising  Income  Derived  from  Medical 
Advertising  in  Certain  Foreign-language  Newspapers 


Language 

Paper 

Location 

Per 
Cent 

Arabian 

Al-Fatat 

Boston 

New  York. .  . 

Boston 

Boston 

New  York... 
Boston 

Chicago 

New  York . .  . 

New  York. .  . 

Omaha 

Fitchburg 

Duluth 

Fall  River... 
Worcester. . , . 
New  York. . . 

Chicago 

New  York. , . 

Lincoln 

Lincoln 

Chicago 

New  York . .  . 
San  Francisco 

New  York. .  . 
New  York. .  . 
Cleveland. . .  . 

5 

Daily  Mirror 

9 

Armenian 

AzJc 

20 

Bahag 

0 

Gotcknag 

0 

Hairenik 

25 

Bohemian 

Amerikan 

11 

New  Yorske  Listv 

30 

Croatian 

Narodni  List 

59 

Danish 

Den  Danske  Pioneer 

10 

Finnish 

Pohjan  Tahti 

5 

Pdivelakti 

20 

French 

L'  Independant 

7 

U Opinion  Publique 

18 

German 

Courrier  des  Etats-Unis 

Abendpost 

10 
10 

New  Yorker  Herold 

12 

D  euts  ch    -  Amerikanischer 
Farmer 

6 

Lincoln  Freie  Presse 

0 

Greek 

Greek  Star 

0 

National  Herald 

10 

Promeiheos 

20 

Hmigarian 

Amerikai  Magyar  Nepszava 
Magyar  Muskaslap 

40 
0 

Szabadsag 

20 

12 


165 


IMMIGRANT  HEALTH  AND  COMMUNITY 


Language 


Italian . 


Lithuanian 

Mixed 

Norwegian. 
Polish 


Paper 


Portuguese. 

Roumanian 
Kussian. . . . 

Slovak 

Slovenian . . 

Spanish 

Swedish . . . 

Ukrainian. . 
.Yiddish... 


7/  Minatore 

II  Progresso-Italo- Americano . 

Bollettino  della  Sera 

L' Italia 

La  Notizia 

La  Voce  del  Popolo 

Lietuva 

Sandara 

Darbininkas 

Amerikos  Lietuvis 

United  Mine  Workers^  Journal 

Tidende 

Pennsylwanski  Gornik 

Ameryka-Echo 

Przewodnik  Katolicki 

Straz 

Kuryer  Codzienny  Bostonski 

Piast 

Dziennik  Dla  Wszystkeck. . . 

0^  Popular 

A  Alvorada 


America 

Russkoye  Slovo 

Amerikansky  Russky  Viestnik 

Nove  Casy 

Krojan 

Slovak  V  Amerike 


Glas  Naroda. 
La  Prensa . . . 


Nordstjernan 

Osterns-Weckoblad 
Svea 


Svoboda 

Jevnsh  Daily  News. 

Vorwarts 

Warheit 


Location 


Scranton 

New  York. .  . 
New  York . .  . 
San  Francisco 

Boston 

Detroit 


Chicago 

South  Boston 

Boston 

Worcester. . . . 
Indianapolis  . 
Minneapolis  . 

Scranton 

Toledo 

New  Britain  . 

Scranton 

Boston 

Chicopee 

Buffalo 


New  Bedford. 
New  Bedford. 

Cleveland — 

New  York . .  . 
Homestead  . . 

Chicago . . 
New  York 
New  York 

New  York 

New  York 

New  York, 
New  Britain 
Worcester. . . 

Jersey  City . 

New  York. . 
New  York. . 
New  York. . 


Per 
Cent 


21^ 

60 

35 

23 

20 

13 

20 

6 

25 

18 

0 
6 

0 
60 
45 
40 
35 

6 
25 

5 
3 


30 
5 

0 
20 
55 

50 

2 
20 

21H 
16 

50 

10 
10 
17 


166 


THE  MEDICAL  QUACK 

It  is  right  to  mention  with  emphasis  a  certain  group 
of  progressive  or  altruistic  papers  whose  publishers 
refuse  medical  advertisements  altogether  or  censor 
the  few  that  they  do  publish.  The  stand  taken  by 
these  papers  is  best  shown  by  quotations  from  their 
letters,  wTitten  in  reply  to  our  request  for  rates. 

This  newspaper  does  not  accept  medical  advertising, 
because  it  cannot  help  entertain  the  feeling  that  most  of 
the  medical  advertisements  in  the  foreign-language  press 
are  not  straight.  Since  it  is  very  hard  to  draw  the  line, 
we  made  it  a  rule  not  to  consider  such  advertising  offers, 
in  spite  of  the  fact  that  the  expenses  of  getting  out  publi- 
cations nowadays  are  mounting  every  day. — Magyar 
Muskaslap  (Hungarian),  New  York  City. 

We  feel  very  sorry  to  state  that  for  some  time  past  our 
paper  has  refused  all  medical  advertisements. — Le  Courier 
Franco- Ajnericain^  Chicago. 

Medical  advertisements  subject  to  approval  of  pub- 
lishers.— Tidende  (Norwegian),  Minneapolis. 

Medical  advertisement  limited  to  business  cards  with 
name,  address,  and  business  hours  of  professional  physicians. 
— Atlantis  (Greek),  New  York  City. 

In  regard  to  our  rate  for  medical  advertisement,  will 
say  that  we  would  desire  to  receive  a  copy  of  the  advertise- 
ment that  you  are  contemplating  to  publish,  as  we  are 
only  accepting  limited  amount  of  medical  advertisements, 
and  we  shall  quote  you  our  advertising  rate. — Den  Danske 
Pioneer  (Danish),  Omaha. 

Before  you  place  your  advertisement  please  let  us  know 
what  nature  is  your  advertisement  going  to  be,  as  we  do 
not  put  advertisement  in  the  paper  that  would  harm  our 
clean  reputation  and  the  readers  of  this  newspaper. — New 
TmEs  Publishing  Company  (Slovak),  Chicago. 

No  special  rates  given  for  medical  advertising.  In  fact, 
we  don't  cater  to  such  advertisements  unless  thej'  are  the 
best  kind.  .  .  . — The  Greek  Star,  Chicago. 

167 


IMMIGRANT  HEALTH  AND  COMMUNITY 

The  Geringer  Press — which  publishes  eight  papers 
for  Bohemians  in  Chicago,  Cedar  Rapids,  Iowa; 
Prague,  Oklahoma;  Baltimore,  Maryland;  and  East 
Pittsburgh,  Pennsylvania — refuses  all  advertisements 
offering  medical  treatment  by  mail,  but  does  accept 
patent-medicine  advertisements. 

Amerikansky  Russky  Viestnik,  Homestead,  Penn- 
sylvania (Russian  and  Slavic  editions),  writes  that 
medical  advertisements  "must  be  devoid  of  reference 
to  private  diseases." 

The  fact  that  four  of  these  publishers  are  in  Chicago 
suggests  that  the  antiquack  campaign  carried  on  by 
the  Tribune,  the  American  Medical  Association, 
Doctor  Krasnow,  and  others  is  showing  positive 
results. 

Nevertheless,  among  more  than  a  hundred  foreign- 
language  newspapers  examined,  a  very  small  pro- 
portion refuse  medical  advertisements.  A  few  more 
accept  them  with  limitations.  Apparently  most 
papers  accept  anything  that  will  bring  in  money.  We 
must  conclude  that  the  majority  of  the  foreign-lan- 
guage newspapers  share  the  profits  of  quackery. 
Some  papers  draw  more  than  half  their  incomes  from 
improper,  illegitimate,  or  fraudulent  medical  ad- 
vertising. ■ 

The  foreign-language  newspapers  are  an  inevitable 
and  necessary  feature  in  American  journalism  as  long 
as  we  have  thousands  of  residents  and  citizens  who, 
whether  or  not  they  read  English,  also  read  their 
mother  tongue.  While  legal  restrictions  upon  certain 
types  of  advertisement  are  urgently  needed,  one  of 
the  most  effective  and  immediate  means  of  diminish- 
ing the  medical  advertising  in  the  foreign-language 

168 


THE  MEDICAL  QUACK 

newspapers  is  to  provide  other  sources  of  income. 
Obviously,  newspapers  that  depend  upon  a  certain 
class  of  advertisements  for  from  20  to  60  per  cent 
of  their  total  receipts  from  advertising  cannot  sud- 
denly surrender  it  and  live. 

The  American  Association  of  Foreign  Language 
Newspapers,  recently  reorganized  under  the  leadership 
of  well-kno^n  business  men,  has  begun  to  call  to  the 
attention  of  American  advertisers  the  opportunities 
offered  by  the  foreign-language  press.  In  the  summer 
of  1919  a  full-page  advertisement  was  printed  prom- 
inently in  leading  American  papers  throughout  the 
country  under  the  heading: 

THE  FOREIGN  MARKET  IN  THE  UNITED  STATES 

WHY    IT    PAYS    THE    BUSINESS   MAN    TO    USE    THE  FOREIGN- 
LANGUAGE   PRESS 

"Here  is  a  new,  large,  and  fertile  field  in  which  to  sell 
your  goods,"  says  the  American  Association  of  Foreign 
Language  Newspapers  to  the  American  advertiser. 
"You  can  make  money  by  using  the  foreign-language 
new^spapers.  At  the  same  time  you  will  be  helping 
to  Americanize  the  foreign  born.  The  American 
standard  of  living  is  developed  through  the  use  of 
American  products,  such  as  toothbrushes,  grapho- 
phones,  sewing  machines,  cash  registers,  candy,  seed, 
harness,  furniture,  books,  banking,  etc.  Good  Amer- 
icanism is  good  business." 

Since  the  foreign-language  newspapers  are  (and 
must  be)  a  factor  in  the  transition  of  the  foreign  born 
from  immigrant  to  American  citizen,  let  us  see  to  it 

that  these  newspapers  introduce  the  best  of  America, 

169 


IMMIGRANT  HEALTH  AND  COMMUNITY 

not  the  worst,  to  their  readers.  Let  us  encourage 
American  business  men  and  women  who  have  credit- 
able goods  to  sell  to  advertise  their  wares  in  the 
foreign-language  press.  The  readers  will  be  benefited 
by  having  an  opportunity  to  buy  American  products, 
and  they  will  become  familiar  with  American  habits 
and  tastes  in  a  perfectly  natural  way.  Then  the 
publishers  who  are  now  struggling  to  keep  their  papers 
going  will  be  able  to  say  to  medical  quacks  and  all 
other  frauds:  "We  don't  want  your  ads;  we  have 
something  better  to  put  before  our  people.  Thank 
you,  but  we  do  not  need  your  money;  our  business  is 
already  very  good." 

The  foreign-language  press  can  be  helpful  in  another 
direction.  Announcement  of  the  worthy  medical 
resources  of  the  community  may  well  be  made  through 
its  columns.  For  instance,  there  may  be  published 
the  names  and  addresses  of  dispensaries  and  hospitals, 
of  nursing  associations,  health  departments,  the  head- 
quarters for  the  public  school's  work  in  hygiene.  Some 
responsible  board,  local  or  state,  ought  to  furnish 
suitable  material  for  such  a  list.  Many  papers  would 
find  their  readers  interested  in  a  health  department; 
many  communities  or  societies  would  find  their  mem- 
bers interested  in  a  health  circle,  with  lectures  from 
doctors  who  speak  their  own  language.  The  foreign- 
language  newspapers  could  encourage  such  circles  by 
announcing  meetings,  reporting  lectures  and  papers 
read,  and  recommending  desirable  books. 

FEDERAL   LEGISLATION 

As  a  weapon  to  deal  with  this  situation  public  opinion 
is  an  effective  but  a  slow  one.     More  immediate  re- 

170 


THE  MEDICAL  QUACK 

suits  can  be  obtained  through  the  operation  of  certain 
state  and  Federal  laws.  One  of  the  most  powerful  of 
these  is  the  Federal  law  commonly  called  the  Fraud 
Order  law.^  This  gives  the  Post  Office  Department 
the  authority  to  close  the  mails  to  anyone  using  them 
in  schemes  to  defraud.  Before  issuing  a  Fraud 
Order  the  Post  Office  authorities  collect  enough 
evidence  to  be  sure  that  the  man  or  concern  is  really 
defrauding  through  the  mails.  There  is  no  public 
trial,  but  a  hearing  before  the  Postmaster-General  or 
his  deputy.  The  quack  has  a  right  to  appeal  to  the 
courts,  but  in  few  cases  has  he  done  so,  and  in  no 
case  has  the  decision  of  the  Post  Office  Department 
been  reversed.  Fraudulent  business  involving  thou- 
sands of  dollars  has  been  wiped  out  by  this  means. 

The  Post  Office  Department  began  the  active  use 
of  this  power  about  1914,  but  up  to  1919  had  hardly 
touched  the  foreign-language  advertisers.  The  report 
of  the  Solicitor-General  of  the  Post  Office  Department 
to  the  Postmaster-General  (1916)  announces  that  the 
use  of  the  Fraud  Order  is  becoming  generally  known 
and  appreciated  and  that  the  movement  among 
publishers  for  truthful  advertising  is  growing.^ 

The  activity  of  the  department  in  prohibiting  the  use 
of  the  mails  for  the  conduct  of  fraudulent  schemes  has 
become  generally  known  to  the  public,  with  the  result 
that  this  office  is  flooded  with  complaints  against  the 
alleged  fraudulent  schemes  from  all  sections  of  the  country. 
It  is  difficult  to  handle  all  of  these  in  an  efficient  way  with 
the   present  force.  .  .  .  This   campaign   for   truthful   ad- 


^  United  States  Criminal  Code,  sec.  215. 

2  Report  of  the  Solicitor  for  the  Post  Office  Department  to  the  Post- 
master-General, for  the  year  ending  June  30,  1916,  p.  5. 

171 


IMMIGRANT  HEALTH  AND  COMMUNITY 

vertlsing  is  resulting  in  a  great  change  in  the  nature  of 
advertisements  carried  by  many  newspapers  and  periodicals, 
and  in  the  conservative  tone  which  is  becoming  more  and 
more  characteristic  of  the  advertising  of  legitimate  business. 
Its  effect  is  also  to  be  seen  in  the  fraudulent  advertising  laws 
which  have  recently  been  passed  by  many  state  legislatures 
and  by  Congress  in  legislating  for  the  District  of  Columbia. 

The  Fraud  Order  is  a  powerful  instrument,  the 
use  of  which  in  a  democratic  society  should  be  care- 
fully safeguarded.  It  should,  however,  be  applied 
much  more  aggressively  to  the  suppression  of  quacks. 
The  number  of  cases  that  the  Post  Office  Depart- 
ment can  investigate  and  prosecute  depends,  of 
course,  on  the  appropriations  available.  Every  dol- 
lar devoted  to  this  work  saves  thousands  of  dollars 
wrung  from  the  poor  and  unfortunate.  Translations 
of  foreign-language  advertising  are  as  necessary  as 
were  translators  in  search  of  disloyalty.  Public 
health  organizations,  medical  and  civic  bodies  should 
urge  the  appropriation  of  sufficient  funds  to  institute 
a  systematic  weeding  out  from  the  foreign-language 
press  of  all  advertisers  which  can  be  reached  by  this 
law. 

There  is  now  pending  before  Congress  a  bill  "to 
prevent  transmission  through  the  mails  of  adver- 
tisements relating  to  the  treatment  of  venereal  dis- 
eases and  certain  sexual  disorders."  Should  this  bill 
become  a  law  it  would  interfere  with  the  business  of 
a  great  number  of  prospering  quacks.  A  number  of 
states  already  have  such  laws  relating  to  posters  and 
circulars.  This  provision  cannot  be  urged  too 
strongly,  and  it  should  be  followed  as  rapidly  as 

public  opinion  permits  by  similar  restraint  of  the 

172 


THE  MEDICAL  QUACK 

exploitation  of  cancer,  tuberculosis,  and  other 
diseases. 

The  "patent"  medicines,  which  are  rarely  pat- 
ented, and  the  proprietary  medicines,  which  are 
practically  identical  with  the  so-called  "patent" 
medicines,  are  covered  by  the  Food  and  Drugs  Act 
of  1906,  commonly  knoTSTi  as  the  Pure  Food  law. 
This  law  has  done  a  great  deal  of  good  by  fixing  re- 
sponsibility for  products  both  in  food  and  in  drugs, 
but  its  common  name.  Pure  Food  law,  has  made  peo- 
ple think  that  everything  bearing  its  guaranty,  name, 
or  number  is  altogether  admirable.  This  is  a  serious 
mistake.  Its  provisions  and  its  field  of  application 
are  both  limited.  The  Food  and  Drugs  Act  applies 
only  to  products  in  interstate  commerce — things 
manufactured  and  sold  within  the  boundaries  of  a 
single  state  are  not  affected. 

If  a  drug  product  is  to  be  sold  in  states  other  than 
the  one  in  which  it  was  manufactured,  it  must  fulfill 
certain  conditions.  Its  "label,"  which  by  the  inter- 
pretation of  the  courts  includes  all  the  contents  of 
the  package,  must  state  whether  it  contains  alcohol, 
morphine,  opium,  cocaine,  heroin,  alpha-eucain  or 
beta-eucain,  chloroform,  canabis  indica,  chloral  hy- 
drate, or  acetanilid,  or  their  derivatives.  These 
eleven  drugs  and  their  derivatives  must  be  declared, 
with  the  amount  of  each  used.  But  other  poisonous 
drugs,  such  as  aconite,  arsenic,  carbolic  acid,  prussic 
acid,  and  strychnine,  may  be  used  and  not  declared. 

The  patent-medicine  manufacturer  must  be  care- 
ful in  the  statements  he  makes  in  the  trade  package, 
which  includes  the  bottle,  its  label,  and  all  circulars, 

boxes,  or  cases  that  go  with  it.     He  must  make  no 

173 


IMMIGRANT  HEALTH  AND  COMMUNITY 

statement  which  is  false  or  misleading  about  the 
composition  and  origin  of  his  medicine,  and  he  must 
be  careful  not  to  make  false  or  fraudulent  claims  for 
its  curative  virtues.  Doctor  Cramp,  of  the  American 
Medical  Association,  puts  this  very  clearly :  ^ 

Under  the  Food  and  Drugs  Act,  then,  the  manufacturer 
of  a  medicinal  product  may  be  declared  guilty  of  mis- 
branding if  the  statements  he  makes  (on  the  trade  package) 
regarding  the  composition  or  the  origin  of  his  products 
are  either  "false  or  misleading";  he  may  also  be  found 
guilty  of  misbranding  if  the  statements  he  makes  (also 
on  the  trade  package)  regarding  the  curative  effects  of 
his  preparations  are  both  "false  and  fraudulent." 

However,  the  patent-medicine  maker  and  seller 
slips  by  Uncle  Sam's  grave  requirements  very  easily 
and  happily.  He  then  betakes  himself  to  the  news- 
papers, in  which  he  can  make  practically  any  boast 
of  the  curative  effects  of  his  medicine.  No  one 
molests  him,  and  the  people  believe  him,  for  in  their 
minds  does  not  the  Pure  Food  law  also  insure  them 
pure  medicines? 

Doctor  Cramp  gives  us  this  clever  rule  for  finding 
the  false  ingredient  in  a  newspaper  advertisement 
for  patent  medicine: 

From  the  claims  made  in  the  newspaper  advertisements 
and  circulars  subtract  those  that  are  made  in  the  trade 
package;  the  difference,  you  are  justified  in  assuming,  is 
falsehood ! 

STATE   LEGISLATION 

Besides  these  Federal  laws,  various  states  deal 
separately  with  the  medical  quack.    During  the  past 

1  Arthur  J.  Cramp,  M.D.,  "The  Nostrum  and  the  Public  Health," 
reprint  from  The  Journal  of  the  American  Medical  Association, 
May  24,  1919,  p.  4. 

174 


THE  MEDICAL  QUACK 

two  years  nine  states  have  passed  laws  prohibiting 
the  advertising  of  treatment  for  venereal  diseases, 
and  in  some  cases  the  advertising  of  nostrums  to 
treat  these  diseases.  This  legislation  was  in  most 
instances  the  result  of  the  war-time  campaign  against 
venereal  diseases.  It  has  undoubted  value,  but  two 
limitations  must  be  pointed  out. 

As  these  are  state  laws,  they  do  not  affect  business 
done  through  the  mails,  as  such.  These  state  laws, 
and  the  Federal  law,  however,  are  mutually  supple- 
mentary, and  each  is  necessary  to  the  other's  most 
complete  effectiveness. 

Quacks  often  get  around  these  laws  by  using  a 
form  of  words  which  does  not  come  strictly  within 
the  wording  prohibited  by  the  terms  of  the  statute. 
Then  they  trust  to  a  narrow  legal  interpretation  to 
save  them  should  they  be  prosecuted. 

In  addition  to  these  special  laws  the  legislation  of 
each  state  in  the  Union  regulates  the  practice  of 
medicine  within  its  own  borders.  These  medical- 
practice  acts  need  to  be  strengthened  in  some  re- 
spects. The  custom  of  recognizing  by  courtesy  and 
without  new  examinations  a  doctor  who  has  been 
registered  and  licensed  to  practice  in  another  state 
covers  many  abuses  of  quackery. 

These  state  laws  regulating  the  practice  of  medicine 
apply  to  obvious  cases.  Under  them  a  man,  posing 
as  a  doctor,  "practicing  medicine'*  without  legal 
license  to  do  so,  can  be  prosecuted  and  convicted. 
So  can  the  licensed  fraud.  A  doctor  who  has  started 
out  honestly  enough  may  fail  to  make  a  success  of 
ethical  practice;  he  may  start  a  profitable  "insti- 
tute" or  a  business  by  mail;   or  he  may  hire  himself 

175 


IMMIGRANT  HEALTH  AND  COMMUNITY 

to  some  *'professor"  and  for  a  small,  regular  salary — 
twenty-five  dollars  to  fifty  dollars  a  week — do  the 
*' examining  and  prescribing"  while  the  '* professor" 
takes  in  from  two  to  eight  thousand  dollars  monthly. 
The  license  of  such  a  man  can  be  revoked,  and  he 
may  be  punished  further  if  he  is  found  guilty  of  ac- 
tually taking  money  with  the  intent  to  defraud. 

The  hospital  or  dispensary  has  only  just  begun  to 
come  under  public  supervision,  although  it  is  sound 
policy  that  any  organization  doing  public  work  should 
be  under  some  degree  of  public  supervision.  The 
delay  has  probably  been  due  to  a  theory  that  the 
public  interests  were  protected  by  the  licensing  of 
individual  practitioners  of  medicine,  who  must  be 
the  active  professional  agents  in  these  institutions. 
It  has  come  to  be  recognized,  however,  that  the  in- 
stitution, as  such,  should  be  under  direct  supervision 
of  a  health  authority  representing  the  public;  conse- 
quently state  or  local  laws  licensing  hospitals  or  dis- 
pensaries are  being  passed.  New  York,  Massachu- 
setts, and  Ohio  are  examples  of  states  in  which  dis- 
pensaries must  be  licensed.  The  Massachusetts  law 
defines  a  dispensary  as  follows: 

Section  I.  For  the  purposes  of  this  act  a  dispensary  is 
defined  to  be  any  place  or  establishment,  not  conducted 
for  profit,  where  medical  or  surgical  advice  or  treatment, 
medicine  or  medical  apparatus,  is  furnished  to  persons  non- 
resident therein;  or  any  place  of  establishment,  whether 
conducted  for  charitable  purposes  or  for  profit,  advertised, 
announced,  conducted  or  maintained  under  the  name  "dis- 
pensary" or  "clinic,"  or  other  designation  of  like  import. 

Any  organization  advertising  itself  as  a  clinic,  dis- 
pensary, or  medical  institute  would  come  under  this 

176 


THE  MEDICAL  QUACK 

law,  and  therefore  under  the  supervision  of  public 
authority.  In  the  case  of  Massachusetts  this  is  the 
State  Department  of  Health,  but  in  Chicago  it  is  the 
City  Department.  In  any  case,  the  license  law  gives 
to  some  public  authority  a  power  to  acquaint  itself 
with  facts  through  inspection,  and  to  use  these  facts 
for  public  information.  During  the  first  year  of 
operation  the  Massachusetts  Dispensary  law,  passed 
in  1918,  put  out  of  business  nine  quack  or  commercial 
dispensaries  in  the  city  of  Boston. 

LAW    ENFORCEMENT 

The  value  of  all  these  laws,  however,  depends  upon 
their  aggressive  enforcement.  Their  purpose  is  often 
defeated  because  the  person  who  has  suffered  from 
the  quack  fails  to  make  a  complaint.  Only  after  the 
public  realizes  that  it  is  being  defrauded  will  it  look 
for  the  law  to  redress  its  grievance.  Many  immi- 
grants are  so  unsuspecting  that  they  are  easily  fooled. 
Even  if  they  do  appreciate  that  they  have  been,  duped, 
their  ignorance  of  English,  or  of  the  means  of  legal 
redress,  usually  renders  them  passive.  It  is  neither 
just  nor  wise  that  the  public  should  thus  place  the 
responsibility  of  initiative  upon  the  individual  who 
is  aggrieved.  An  aggressive  public  agency,  rather 
than  a  passive  one,  is  needed  for  the  adequate  pro- 
tection of  the  immigrant  against  the  medical  quack. 
Beginnings  in  this  direction  have  been  made  by 
various  agencies,  both  public  and  private.  Promi- 
nent among  these  are  the  state  bureaus  of  immigra- 
tion.    The  California  Commission  of  Immigration 

and  Housing,  whose  work  is  notable  in  so  many  ways, 

177 


IMMIGRANT  HEALTH  AND  COMMUNITY 

has  received  and  dealt  with  complaints  of  medical 
frauds,  but  as  yet  it  has  not  taken  up  any  special 
campaign  against  this  evil.  The  Massachusetts 
Bureau  of  Immigration  is  too  recent  to  have  devel- 
oped this  work,  but  it  is  studying  the  subject.  The 
longer  established  Bureau  of  Industries  and  Immi- 
gration, in  New  York  State,  which  is  a  branch  of  the 
State  Department  of  Labor,  has  accomplished  more 
in  this  direction. 

Many  immigrants  are  slow  to  voice  their  troubles 
except  to  people  or  to  an  organization  which  has 
won  their  confidence,  and  for  this  reason  the  estab- 
lishment of  bureaus  of  immigration  under  state  or 
city  auspices  is  a  desirable  movement,  by  whatever 
title  they  may  be  called.  In  planning  such  bureaus 
full  provision  should  be  made,  both  in  the  organiza- 
tion and  in  the  appropriations,  for  sufficient  power  to 
receive,  investigate,  and  deal  with  complaints  of 
medical  fraud.  Such  bureaus  should  be  prepared  to 
make  investigations  on  their  own  account  and  to 
awaken  public  opinion,  so  as  to  secure  support  for 
vigorous  enforcement  of  the  law  and  for  adequate 
sentences  for  the  quacks. 

Voluntary  organizations  dealing  with  health  prob- 
lems can  assist  here.  Public  health  committees,  anti- 
tuberculosis societies,  nursing  associations,  can,  by 
publicity  as  well  as  through  direct  co-operation  with 
bureaus  of  immigration,  reveal  instances  of  quack- 
ery and  awake  the  public  to  its  meaning.  Not  a 
few  medical  societies,  notably  that  of  New  York 
County,  have  undertaken  work  along  this  line. 

It  would  seem  to  be  good  policy  for  a  medical 

society  to  act  as  an  investigating,  stimulating,  and 

17S 


THE  MEDICAL  QUACK 

publicity  agent,  rather  than  a  prosecuting  body. 
Certain  elements  among  the  public,  newspapers,  and 
even  courts  discount  what  the  medi?al  profession 
does  or  attempts  to  do  against  quacks,  on  the  ground 
that  one  business  competitor  is  attacking  another. 
Ill-founded  as  this  feeling  is,  it  must  be  reckoned 
with. 

The  Health  Department  of  a  city  has  authority 
with  the  sources  of  publicity  in  the  newspapers  and 
elsewhere.  They  look  upon  the  Health  Department 
as  the  natural  agency  to  speak  in  a  definitive  way 
regarding  any  medical  or  health  question.  In  en- 
lightening the  public  concerning  the  evil  doings  of 
the  quack,  the  powers  of  the  Health  Department  are 
limited  only  by  the  courage  of  the  commissioner  and 
his  judgment  of  the  educational  and  political  effects 
of  a  campaign  that  might  be  construed  as  an  attack 
by  certain  medical  institutes  or  by  patent-medicine 
interests.  Few  departments  have  made  use  of  the 
power  they  might  wield  through  bureaus  of  public 
health  education,  or  through  their  general  activities 
if  they  have  no  such  special  bureau,  to  protect  the 
public  against  the  quack. 

The  experience  of  the  New  York  Department  of 
Health  in  connection  with  patent-medicine  venders 
is  of  interest.  In  1915  the  New  York  City  Board  of 
Health  passed  an  ordinance  requiring  that  the  in- 
gredients of  all  packages  of  patent  medicines  be 
printed  on  the  label.  The  powers  under  which  this 
ordinance  was  passed  were  the  general  sanitary 
powers  of  the  department  to  protect  and  promote 
the  public  health.     The  ordinance  was  contested  in 

the  courts,  and  was  finally  declared  unconstitutional 

179 


IMMIGRANT  HEALTH  AND  COMMUNITY 

by  the  New  York  State  Court  of  Appeals,  but  the 
ruling  of  the  court  was  on  the  technicality  that  the 
ordinance  had  not  provided  for  the  protection  of  the 
property  of  those  who,  previous  to  the  passage  of 
the  Act,  had  in  stock,  or  had  prepared  for  sale, 
proprietary  medicines  not  properly  labeled. 

The  principle  of  the  law  requiring  publicity  of  the 
ingredients  of  each  package  and  the  authority  of  the 
department  to  pass  such  an  ordinance  were  not  de- 
clared unconstitutional  by  the  court's  decision.  It 
is  much  to  be  hoped  that  departments  of  health  will 
undertake  to  enact  and  enforce  ordinances  of  this 
character,  and  have  them  suitably  tested  in  the 
courts.  Public  opinion  is  moving  forward  so  rapidly 
in  these  matters  that  the  reasonableness  of  the  re- 
quirement that  the  ingredients  of  a  medicine  be 
printed  on  its  label  ought  soon  to  meet  the  approval 
of  everyone  who  has  no  special  interest  to  serve. 

Although  these  various  agencies  have  power  to 
fight  the  quack  and  may  in  time  develop  it  ade- 
quately, the  results  so  far  accomplished  are  not 
encouraging.  The  following  cases  are  reported  by 
the  Bureau  of  Industries  and  Immigration  in  New 
York  State.i 

One  of  these  offices,  operating  in  the  name  of  "Doctor 
Hannon,"  but  in  charge  of  a  man  named  Noack,  recently 
demanded  and  received  $130  as  a  first  payment  for  a 
guaranteed  "cure."  This  "doctor"  was  one  of  those  who 
had  received  a  suspended  sentence  when  convicted  in  1915, 
and  this  bureau  was  obliged  to  determine  whether  the 
poor  immigrant  should  lose  his  money  or  proceed  again  to 
prosecute  Noack.    A  demand  was  made  for  the  immediate 

^  Annual  Report,  New  York  State  Bureau  of  Industries  and  Immi- 
graiion,  1916,  p.  9. 

180 


THE  MEDICAL  QUACK 

return  of  the  money,  and  Xoack,  accompanied  by  two  at- 
torneys, appeared  at  this  office.  The  next  day  a  check  was 
received  for  the  entire  amount. 

Further  extracts  from  the  reports  illustrate  the 
urgent  needs  for  adequate  punishment  of  the  re- 
sponsible person:^ 

Investigations  conducted  by  the  bureau  show  that  these 
museums  and  their  so-called  "doctors"  obtained  many 
thousands  of  dollars  weekly,  defrauding  foreigners.  The 
proprietor  of  one  of  the  larger  offices  stated  that  unless 
the  profits  averaged  $4,000  a  month  it  would  be  closed. 
One  of  the  worst  offenders  was  a  man  named  Henry  J. 
Shireson. 

This  man  Shireson  was  prosecuted  for  violation  of 
the  Public  Health  law,  convicted,  and  sentenced  to 
six  months  in  the  penitentiary. 

Now  read  this  from  the  report  ^  of  the  same  bureau 
for  the  very  next  year,  1916: 

During  the  year  one  Henry  J.  Shireson,  who  had  served 
six  months  in  the  penitentiary  in  this  state,  was  released. 
He  immediately  opened  an  office  in  Utica  under  the  name  of 
Doctor  Fanning  and  with  his  female  confederate  proceeded 
to  advertise  and  distribute  the  old  familiar  t^-pe  of  circular. 
He  succeeded  in  swiudliag  the  immigrant  population  of 
Oneida  County  of  about  $36,000  in  about  six  weeks.  At  the 
same  time  he  had  opened  an  office  in  Schenectady  and  accu- 
mulated about  $14,000.  He  was  indicted  for  grand  larceny 
in  Utica  and  escaped;  his  assistant.  Doctor  Fanniug,  who 
was  employed  at  a  salary  of  $25  per  week  as  the  dupe  of 
this  cruniaal,  is  now  serving  a  term  on  an  indeterminate 
sentence  of  from  five  to  ten  years  in  the  Auburn  state 
prison.  The  record  of  Shireson  appears  in  the  previous 
report  of  this   bureau,   but  his  reappearances   in  highly 

^  Annual  Report,  New  York  State  Bureau  of  Industries  and  Immi- 
gration,  1915,  p.  15.  2  7^,:^.^  1916,  p.  8-9. 

13  181 


IMMIGRANT  HEALTH  AND  COMMUNITY 

populated  immigrant  sections  of  the  country  is  to  be  ex- 
pected as  long  as  he  remains  at  large.  He  has  been  termed 
a  dangerous  criminal  by  the  authorities  of  various  other 
states  and  is  a  serious  menace  to  the  community,  since  he 
not  only  swindles  these  ignorant  people  of  their  entire 
savings,  through  appeals  to  their  sense  of  self-preservation, 
but  operates  to  the  detriment  of  life  and  health  by  his 
unscrupulous  deception,  errors  of  diagnosis,  and  improper 
treatment. 

Leonard  Landes  was  prosecuted  in  New  York  by 
this  bureau  in  1915,  and  given  thirty  days  and  a  fine 
of  one  hundred  dollars.  This  is  probably  the  "Leo 
Landes'*  whose  advertisements  we  found  in  twelve 
different  papers.  No  wonder  that  the  quack  can 
pay  so  much  for  advertising  when  he  is  taking  in  so 
much  cash  daily.  No  wonder  he  doesn't  mind  a 
small  fine  and  a  short  prison  term  when  his  business 
can  go  on  during  his  absence  or  be  easily  re-estab- 
lished when  he  returns. 

The  only  ultimate  protection  for  the  individual 
against  fraud  lies  in  himself.  But  the  educational 
process  which  develops  wisdom  in  the  individual  is 
slow,  so  slow  that  we  cannot  depend  on  it  to  remedy 
urgent  existing  evils.  The  more  quickly  effective 
measures  of  legislation  and  administration  must  be 
utilized,  while  we  still  hammer  at  the  long-range 
constructive  work  of  education. 

One  of  the  chief  characteristics  of  the  quack  is  his 
cleverness.  We  can  learn  from  him.  The  use  of  the 
foreign-language  newspapers  by  quacks  demonstrates 
that  most  of  these  medical  advertisers  are  scoundrels, 
ignorant  of  medical  science,  but  clever  commercial- 
ists  and  expert  practical  psychologists.  The  manner 
in  which  they  appeal  to  the  immigrant,  the  methods 

182 


THE  MEDICAL  QUACK 

which  they  use,  are  well  worthy  of  study.  Govern- 
mental agencies,  health  departments,  private  health 
organizations  of  all  kinds,  may  well  imitate  the  quack 
in  devising  clever  ways  to  reach  the  immigrant,  in 
learning  to  understand  him  and  what  will  appeal  to 
him.  They  will  use  this  knowledge  and  power,  of 
course,  not  to  rob  him  and  ruin  his  health,  but  to 
give  him  larger  facilities  for  life  and  the  pursuit  of 
happiness. 


IX 

BIRTH    RATES   AND   MATERNITY   CUSTOMS 

The  kind  of  care  which  women  receive  during  the 
puerperal  period  is  not  only  of  great  importance  to 
the  mother's  comfort  and  future  health,  but  also  de- 
termines to  a  considerable  degree  the  infant  mor- 
tality rate  and  the  health  and  efficiency  of  the  next 
generation.  If  there  is  a  difference  in  the  care  re- 
ceived by  the  native  and  the  foreign-born  woman 
during  and  after  childbirth,  it  may  account  for  the 
high  infant  mortality  rate  of  our  white  stock  of  for- 
eign extraction. 

FECUNDITY  AND  MATERNITY  DEATH  RATES 

Maternity  care  is  particularly  important  to  the  health 
of  the  foreign  born  because  of  the  high  fecundity  of 
immigrant  women,  and  the  high  death  rate  for 
mothers  as  well  as  infants.  The  Immigration  Com- 
mission's Report  on  the  "Fecundity  of  Immigrant 
Women"  records  in  1900  that  the  average  number 
of  children  born  to  women  less  than  forty-five  years 
of  age  and  married  ten  to  nineteen  years  was  2.7 
for  native-born  mothers  and  4.4  for  foreign-born 
mothers.^  Further  comparisons  made  in  1909  of  the 
fecundity  of  married  women  of  the  "old"  and  "new" 

^  Reports  of  the  Immigration  Commission,  vol.  ii,  p.  497. 

184 


BIRTH  RATES  AND  MATERNITY  CUSTOMS 

immigration  show  that  the  former  averaged  3.5  chil- 
dren and  the  latter  4.9.^  The  use  of  the  terms  "old" 
and  "new"  immigration  has  been  discredited  since 
the  report  of  the  commission  was  published,  but  the 
contrast  in  birth  rates  between  certain  races  is  never- 
theless worth  observing. 

A  more  recent  study  of  comparative  birth  rates 
was  made  by  Eastman  for  New  York  State  in  1916. ^ 
Although  his  figures  are  not  exactly  comparable  with 
the  foregoing,  the  same  marked  difference  between 
the  fecundity  of  the  native  and  the  foreign-born 
mother  is  apparent.    The  average  number  of  legiti- 


TABLE  XXIII 

Infant  Mortality  in  European  Countries,  1908  ^ 


Great  Britain . . . 

Denmark 

Norway 

German  Empire 

Austria 

Hungary 

Netherlands . . . . 

France 

Switzerland 

Italy. .^ 

Bulgaria 

Russia 


Birth  Rate 
PER  1,000 

Death  Rate 
PER  1,000 

Infant 

Mortalitt 

PER  1,000 

Births 

26 

15 

118 

28 

14 

106 

26 

14 

76 

32 

18 

178 

33 

22 

204 

36 

24 

199 

29 

15 

125 

20 

19 

143 

27 

16 

108 

33 

22 

153 

40 

24 

170 

48 

30 

256 

1  Peter  Roberts,  The  New  Immigration,  1914,  pp.  368-369. 
(Appended  material  abstracted  from  Immigration  Commission's 
Report  on  "Fecundity  of  Immigrant  Women,"  pp.  46-52.) 

2  P.  R.  Eastman,  New  York  State  Department  of  Health. 
A  Comparison  of  the  Birth  Rates  of  Native  and  of  Foreign-born 
JVhite  Women  in  the  State  of  New  York  During  1916,  1916,  p.  3. 

3  Peter  Roberts,  The  New  Immigration,  1912,  p.  373. 

185 


IMMIGRANT  HEALTH  AND  COMMUNITY 

mate  births  to  every  1,000  married  women  fifteen  to 
forty-four  years  of  age  was  137.1  for  the  native  born 
and  253.2  for  the  foreign  born.  On  an  average  almost 
twice  as  many  children  were  born  to  foreign-born 
mothers  as  to  native  born.  There  is  also  evidence  that 
a  greater  proportion  of  births  were  to  mothers  of  the 
more  recent  immigration,  for  "73.1  per  cent  of  all 
births  to  foreign-born  women  were  to  Italian,  Russian, 
and  Austro-Hungarian  mothers."  These  high  fecun- 
dity rates  among  the  four  races — Poles,  Bohemians 
(or  Czechs),  Russians,  and  Italians — are  of  interest  in 
connection  with  the  infant  mortality  rates  reported 
from  these  European  countries  (Table  XXIII). 
Figures  relating  to  maternal  deaths  among  these 

TABLE  XXIV 

Death  Rates  fbom  Affections  Connected  with  Pregnancy, 
1900.1  (Deaths  per  100,000  Female  Population,  Fifteen 
to  Forty-nine  Years  of  Age,  in  the  Registration  Area) 


White  Motheks  Bobn  in 


United  States . 


Italy 

Russia 

Poland , 

Hungary , 

Germany 

England  and  Wales . 

Scandinavia 

Canada 

Ireland 

Scotland 

Bohemia 

France 

Other  foreign 


Death  Rate 


34.7 

121.7 
66.2 
54.7 
52.6 
52.7 
50.7 
45.7 
45.6 
45.1 
33.7 
30.6 
22.5 
65.3 


1  Twelfth  Census  of  the  U.  S.,  1900,  Vital  Statistics,  vol.  iii,  p. 
ccxlviii. 

186 


BIRTH  RATES  AND  INI/VTERNITY  CUSTOMS 

races  are  scarce.  The  United  States  Census  of  1900, 
however,  contains  some  suggestive  material  (Table 
XXIV) .  The  Italians,  Russians,  and  Poles  head  the  list 
in  maternal  mortality,  standing  in  very  much  the  same 
position  as  in  the  preceding  table  giving  infant  mor- 
tality rates  abroad.  The  amount  of  evidence  on 
hand  is  insufficient  to  reach  any  conclusion  as  to 
whether  the  cause  of  high  maternity  death  rates  is 
racial  or  environmental,  or  as  to  the  relative  impor- 
tance of  these  two  influences.  The  differences  be- 
tween races  are  so  considerable  and  the  subject  itself 
is  of  so  much  importance  that  further  investigation 
is  much  to  be  desired.  It  is  to  be  hoped  that  figures 
secured  from  the  1920  census  may  be  tabulated  so 
as  to  bring  out  race  elements  in  maternal  mortality. 

INADEQUATE  MATERNITY  CARE 

It  might  be  expected  that  the  same  resources  for 
maternity  care  would  be  used  by  immigrant  women  as 
by  natives  of  the  same  economic  status.  In  large 
cities  there  are  usually  maternity  hospitals  and  char- 
itable agencies  which  are  not  found  in  middle-sized 
communities.  In  cities  where  medical  schools  exist 
and  medical  students  are  taught  obstetrics,  well- 
organized  out-patient  services  have  been  developed, 
through  which  many  women  receive  excellent  care 
in  confinement  in  their  own  homes,  the  difficult  cases 
being  brought  to  the  hospitals.  In  smaller  places 
there  are  no  organized  resources  for  providing  care 
in  confinement,  and  maternity  beds  in  hospitals  to 
which  cases  can  be  taken  in  an  emergency  are  often 

lacking  or  are  far  below  the  number  needed.     The 

187 


IMMIGRANT  HEALTH  AND  COMMUNITY 

facilities  in  rural  districts  are  still  more  limited,  and 
women  must  depend  upon  attendants  privately 
engaged. 

Yet  even  in  large  cities  cases  unattended  by  physi- 
cian, midwife,  or  nurse,  or  even  by  a  neighbor,  are 
far  from  unknown.  In  a  study  of  maternity  care 
made  in  Detroit  in  1917  appears  the  following 
story:  ^ 

Mrs.  K.,  Hungarian,  has  four  children.  Husband 
acted  as  interpreter.  When  asked  if  a  doctor  or  midwife 
was  employed  he  replied:  "Oh,  she  had  her  baby  while 
I  was  at  work — only  the  children  here.  She  sat  up  in  bed 
and  cared  for  herseK.  Was  out  of  bed  on  the  second 
day  after  birth." 

In  this  same  survey  of  2,000  maternity  cases  in  De- 
troit, it  was  found  that 

...  in  the  great  majority  of  instances  the  time  the 
patient  remained  in  bed  was  determined,  not  by  her  physical 
condition,  but  by  the  assistance  she  was  able  to  secure. 
The  presence  of  boarders  or  roomers  in  the  house  at  such 
times  very  materially  shortens  the  time  a  mother  is  cared 
for  in  bed.  Nationality  also  plays  some  part.  It  was 
found  that  daughters  of  foreign-born  mothers  remamed  in 
bed  much  longer  than  their  mothers  had  been  accustomed 
to.  Foreign-born  women  who  came  to  the  United  States 
at  an  early  age  and  received  their  education  in  this  country 
followed  the  customs  of  American  women,  rather  than  their 
relatives  or  fellow  countrywomen.  They  remained,  as  a 
rule,  longer  in  bed  and  had  a  distinctly  higher  standard 
of  care. 

In  a  study  made  in  New  York  by  the  Association 
for  the  Improvement  of  the  Condition  of  the  Poor, 

i"How  Two  Thousand  Detroit  Mothers  Were  Cared  for  in 
Childbirth,"  Detroit  Home  Nursing  Association,  Detroit,  1917, 
p.  11. 

188 


BIRTH  RATES  AND  MATERNITY  CUSTOMS 

in  two  hundred  and  sixty-jfive  maternity  cases  cared 
for  by  midwives,  data  showing  the  rest  period  after 
childbirth  are  of  interest. 

TABLE  XXV 

Days  in  Bed  after  Delivery  of  Cases  Cared  for  by  Midwives, 

New  York  City,  1912-19 


Under 
2  Days 

2  TO  4 

4  TO  6 

6  TO  8 

8    AND 

Over 

Total 

Number 

4 

58 

100 

73 

30 

265 

Per  Cent 

1.5 

21.9 

37.7 

27.5 

11.3 

100 

Over  60  per  cent  of  the  women  delivered  by  mid- 
wives  stayed  in  bed  only  six  days  or  less,  while  four 
women  were  in  bed  less  than  two  days.  What  the 
effects  of  these  short  periods  of  rest  after  childbirth 
may  be  on  mortality  rates  is  a  matter  for  conjecture. 

Conditions  that  existed  a  few  years  ago  in  a  city 
of  middle  size  and  that  are  still  characteristic  of  many 
similar  cities  which  we  have  studied,  are  depicted  in 
the  survey  of  Johnstown,  Pennsylvania,  by  the  Fed- 
eral Children's  Bureau,  published  in  1915.^ 

Two  thirds  of  those  having  no  attendant  (at  birth)  were 
Serbo-Croatians.  It  was  a  Polish  woman,  however,  who 
gave  the  following  account  of  the  birth  of  her  last  child: 

At  five  o'clock  Monday  evening  went  to  sister's  to  return 
washboard,  having  just  finished  day's  washing.  Baby  born 
while  there;  sister  too  young  to  assist  in  any  way;  woman 
not  accustomed  to  midwife,  anyway,  so  she  cut  cord  herseK; 
washed  baby  at  sister's  house;  walked  home,  cooked  supper 
for  boarders,  and  was  in  bed  by  eight  o'clock.  Got  up  and 
ironed  next  day  and  day  following;  it  tired  her,  so  she  then 
stayed  in  bed  two  days.    She  milked  cows  and  sold  milk 

^  Emma  Duke,  "Infant  Mortality,  Johnstown,  Pennsylvania," 
Children's  Bureau,  United  States  Department  of  Labor,  1915, 
pp.  32-34. 

189 


IMMIGRANT  HEALTH  AND  COMMUNITY 

day  after  baby's  birth,  but,  being  tired,  hired  some  one  to 
do  it  later  in  week. 

This  woman  keeps  cows,  chickens,  and  lodgers;  also  earns 
money  doing  laundry  and  char  work.  Husband  deserts  her 
at  times;  he  makes  $1.70  a  day.  A  fifteen-year-old  son 
makes  $1.10  a  day  in  coal  mine.  Mother  thin  and  wiry; 
looks  tired  and  worn.    Frequent  fights  in  home. 

Frequently  the  Serbo-Croatian  women  dispense  alto- 
gether with  any  assistance  at  childbirth;  sometimes  not 
even  the  husband  or  a  neighbor  assists.  More  than  30  per 
cent  of  the  births  among  the  women  of  this  race  took  place 
without  a  qualified  attendant.  More  than  one  half  of  those 
delivered  by  midwives,  less  than  one  fifteenth  of  those  de- 
livered by  physicians,  and  about  one  fifth  of  those  delivered 
without  a  qualified  attendant  had  babies  who  died  in  their 
first  year  of  life. 

Fifteen  of  the  nineteen  Serbo-Croatian  women  whose 
babies  died  under  one  year  of  age  kept  lodgers. 

The  native  mother  usually  had  a  physician  at  childbirth; 
the  foreign  born,  a  midwife.  The  more  prosperous  of  the 
foreign  mothers,  however,  departed  from  their  traditions  or 
customs  and  had  physicians,  while  the  American-born  moth- 
ers, when  very  poor,  resorted  to  midwives.  The  midwives 
usually  charged  $5,  and  sometimes  only  $3;  they  waited  for 
payment  or  accepted  it  in  installments,  and  they  performed 
many  little  household  services  that  no  physician  would 
think  of  rendering. 

One  or  two  of  the  intelligent  graduate  midwives  in  Johns- 
town have  been  an  educational  force  among  the  foreign 
mothers  for  some  years  past.  On  the  other  hand,  there  were 
others  who  were  so  dirty  and  so  ignorant  that  they  were  a 
menace  to  the  public  health. 

BACKGROUNDS  FOR  MOTHERHOOD 

If  neglect  in  confinement  is  more  frequent  for  immi- 
grant than  for  native  women,  the  explanation  may 
be  found  in  various  circumstances  peculiar  to  the 
immigrant's  situation  in  America. 


190 


\ 


BIRTH  RATES  AND  MATERNITY  CUSTOMS 

Earlier  chapters  of  this  volume  have  described  the 
typical  social  and  economic  conditions  under  which 
immigrant  families  live  in  American  communities. 
Poverty  and  crowding,  unsanitary  houses  and  neigh- 
borhoods, are  so  frequent  as  to  be  almost  character- 
istic, whether  it  is  the  immigrant's  own  fault  or  the 
fault  of  the  American  community,  or  some  of  each. 
Maternity  care  under  these  economic  and  social  con- 
ditions presents  difficult  problems  at  best,  but  it  is 
further  complicated  by  barriers  of  language  and  dif- 
ferences in  customs  and  points  of  view  between  the 
American  medical  and  health  worker  and  the 
immigrant. 

No  events  of  life  are  more  interwoven  with  tradi- 
tion and  superstition  than  are  pregnancy  and  birth. 
It  is  impossible  to  understand  the  situation  which 
must  be  dealt  with  among  immigrant  women  in  this 
country  unless  we  know  something  of  their  back- 
grounds and  customs.  Some  of  these  are  of  interest 
merely  to  the  curious;  some  have  practical  value  for 
the  health  worker.  It  must  be  borne  in  mind  that 
in  different  parts  of  a  single  country,  such  as  Italy 
or  Poland,  these  customs  and  traditions  may  vary 
widely,  and  that  what  is  told  one  by  a  certain  Italian 
mother  as  a  long-rooted  custom  of  her  country  may 
really  be  only  a  local  one  of  her  community  or 
district. 

Numberless  traditions  cluster  about  the  care  of 
the  mother.  A  nurse  who  had  had  much  experience 
working  in  Polish  sections  says: 

As  soon  as  a  Polish  woman  is  pregnant  she  gets  a  scrub- 
bing job.  No  matter  what  her  work  may  have  been  before, 
she  now  wishes  to  scrub. 

191 


IMMIGRANT  HEALTH  AND  COMMUNITY 

If  there  is  a  theory  behind  this  it  is  probably  that  the 
exercise  is  good  for  the  prospective  mother.  This 
woman  was  told  that  in  Poland  "a  countess  will 
scrub  when  she  knows  that  a  baby  is  coming." 

Many  Italian  women  are  found  to  have  a  "super- 
stition" against  taking  a  bath  during  pregnancy. 
They  tell  nurses  that  this  will  cause  an  abortion  or 
miscarriage.  A  wise  nurse,  who  had  lived  in  south- 
ern Italy,  observed  that  their  bathing  there  had  been 
in  the  streams,  lakes,  or  sea;  the  shock  of  cold-water 
bathing  possibly  brought  trouble  to  the  pregnant 
woman  and  may  have  been  the  source  of  a  tradition 
against  any  bathing  during  pregnancy.  This  nurse 
is  accustomed  to  explain  carefully  to  her  patients 
that  while  it  was  not  well  to  bathe  in  Italy  in  cold 
water,  out  of  doors,  here  in  America  the  custom  is 
to  take  a  warm  bath  indoors,  and  that  the  bath  will 
be  a  comfort  to  the  mother  and  help  to  keep  her  well. 

A  frequent  Jewish  superstition  seems  to  be  that 
"a  pan  of  water  set  under  the  bed  of  a  woman  in 
confinement  will  keep  away  poisons  and  bedsores." 
A  Russian-Jewish  superstition  told  by  some  mid- 
wives  is  that  a  pregnant  woman  must  not  look  on 
the  face  of  a  dead  person,  or  the  baby  will  be  born 
white.  Another,  that  after  the  baby  is  born,  if  the 
mother  will  blow  into  a  bottle,  the  placenta  will 
come  and  all  will  be  well.  Workers  among  the  Poles 
tell  of  the  same  bottle-blowing  superstition.  It  has 
been  suggested  by  some  doctors  and  nurses  that  the 
muscular  exertion  of  hard  blowing  may  be  of  assist- 
ance in  labor.  Russians  and  Greek  Catholics  appear 
to   have   a   tradition   that   the   mother   should   be 

churched  between  four  and  six  weeks  after  delivery. 

192 


BIRTH  RATES  AND  MATERNITY  CUSTOMS 

One  organization  working  with  numbers  of  these 
people  is  taking  advantage  of  this  custom  by  getting 
the  women  to  go  to  a  clinic  on  that  same  day  for  post- 
partem  examination. 

Similarly,  superstitions  or  customs  regarding  the 
care  of  the  baby  are  numerous.  The  "Evil  Eye"  is 
a  prevalent  superstition  among  many  immigrants 
from  the  Near  East.  "It  is  particularly  bad  to  leave 
a  baby  naked,"  says  one,  "for  if  the  Evil  Eye  then 
falls  on  him  bad  luck  is  soon  on  the  way."  Some 
Polish  mothers  apparently  believe  that  if  water 
touches  a  baby  during  the  first  week  it  will  die  before 
the  end  of  the  first  year. 

The  customs  of  celebration  at,  or  shortly  after,  the 
time  of  the  baby's  birth  are  of  much  importance. 
The  ceremony  of  circumcision  among  the  Jews,  usu- 
ally at  the  end  of  a  baby  boy's  first  week  of  life,  is 
one  example.  Visiting  and  festivity  to  celebrate  the 
birth  of  a  baby  are  frequent  among  many  groups. 
Some  of  these  customs  explain  the  unwillingness  of 
immigrant  women  to  go  to  hospitals  for  confinement. 
Visitors  in  the  hospital  must  necessarily  be  restricted. 
Families  and  friends  cannot  come  and  go  at  will  to 
see  mother  and  baby,  as  they  can  in  the  home. 
What,  then,  is  to  become  of  an  Italian  custom  that 
all  the  friends  and  relatives  should  come  the  day 
after  the  baby  is  born  to  wish  him  luck  and  a  happy 
life?  Charms  and  presents  are  brought  the  baby, 
and  pinned  on  his  clothing.  Italian  w^omen  will  ap- 
proach their  confinement,  particularly  their  first, 
with  wonderful  hand- woven  linen  sheets,  embroidered 
pillowcases,  and  beautiful  satin  coverlets,  often  made 
by  the  mother  herself  during  girlhood.     What  will 

193 


IMMIGRANT  HEALTH  AND  COMMUNITY 

be  the  use  of  these  if  she  goes  to  the  hospital,  where 
she  cannot  use  them,  and  where  her  friends  cannot 
come  to  see  her  lying  in  state  amid  her  finery? 

Such  customs  are  real  parts  of  life.  If  American 
workers  for  health  do  not  know  them  or  understand 
them,  if  they  take  an  indifferent  or  contemptuous 
attitude  toward  them,  they  can  neither  get  the  best 
from,  nor  give  the  best  to,  the  people  whom  they 
seek  to  serve. 

These  few  customs,  traditions,  and  superstitions 
have  been  mentioned  to  illustrate  the  importance  of 
knowing  the  people  with  whom  we  are  dealing,  their 
backgrounds  and  characteristics.  There  has  been  no 
thought  of  holding  up  to  laughter  or  scorn  any  peo- 
ple, or  even  any  superstition.  They  are  historical 
products  of  human  development. 

The  social  composition  of  the  immigrant  family 
creates  another  difficulty  for  the  American  health 
worker.  The  immigrant  mother  has  not  the  inde- 
pendence of  the  average  American-born  woman. 
Authority  over  all  the  members  of  a  family,  including 
the  wife  herself,  is  centered  much  more  in  the  hus- 
band. Now  the  man  of  the  family  is  often  a  difficult 
person  for  the  health  worker  to  reach.  He  is  not  at 
home  during  the  usual  working  hours  of  the  social 
worker  or  nurse.  A  medical  adviser  of  a  child- welfare 
undertaking  in  a  large  Middle  Western  city  tells  us 
that  she  found  it  necessary  to  put  some  nurses  on 
at  night  to  visit  their  immigrant  families,  because 
in  that  particular  group  the  mother  would  not  change 
the  baby's  diet,  however  deleterious  it  seemed  to  the 
American   doctor  or  nurse,   without  receiving  the 

father's  permission. 

194 


BIRTH  RATES  AND  MATERNITY  CUSTOMS 

The  necessity  of  reconciling  inherited  customs  with 
the  conditions  found  in  America  has  in  many  respects 
a  far-reaching  effect  on  maternity  work  for  immigrant 
women.  Perhaps  the  respect  in  which  they  differ 
most  sharply  from  native  born  is  in  their  extensive 
use  of  midwives. 

The  immigrant  mother  has  rarely  been  accustomed 
to  a  man  doctor  at  the  time  of  confinement.  She  and 
her  friends  have  used  the  midwife,  who,  in  most 
European  countries,  is  a  woman  of  some  standing, 
trained,  and  in  many  countries  carefully  supervised. 
The  midwife  is  the  most  important  single  element  in 
the  general  question  of  the  care  of  immigrant  mothers, 
and  as  such  her  capability  and  the  quality  of  her 
work  is  of  immense  importance. 


X 

THE    MIDWIFE 

MiDWiVES  in  the  United  States  bring  into  the  world 
more  than  a  million  babies  every  year.  Although  we 
have  no  exact  records  for  the  country  as  a  whole, 
information  received  from  a  number  of  states  and 
many  cities  show  it  to  be  a  conservative  estimate 
that  30  per  cent  of  all  confinements  are  attended  by 
midwives.  The  truth  is  probably  nearer  40  per  cent 
than  30  per  cent. 

Smaller  detailed  studies  have  been  made  from  coast 
to  coast.  Boston  has  no  official  data,  since  midwives 
are  not  recognized  by  law  in  Massachusetts,  and 
theoretically  are  not  allowed  to  practice.  Ninety 
mothers,  selected  at  random  from  those  attending 
the  general  clinic  of  the  Maverick  Dispensary  in 
East  Boston,  two  years  ago,  reported  that  of  their 
329  children  born  in  this  country,  59  per  cent  had 
been  delivered  by  doctors,  25  per  cent  by  midwives, 
15  per  cent  by  institutions,  and  three  cases,  or  1  per 
cent,  had  been  unattended. 

Of  529  mothers  who  received  prenatal  supervision 
from  the  Division  of  Child  Hygiene  of  the  Depart- 
ment of  Health  in  Newark,  New  Jersey,  87.3  per 
cent  were  delivered  by  midwives,  9.6  per  cent  by 
doctors,  2.6  per  cent  in  hospitals,  and  .4  per  cent 
had  no  attendant.  The  number  who  used  midwives 
is  notable,  since  up  to  the  time  of  delivery  nurses  of 

196 


THE  MIDWIFE 


the  Department  of  Health  had  been  supervising  their 
pregnancy. 

Variation  in  the  per  cents  reported  from  the  dif- 
ferent places  intimates  that  nationality  must  be 
taken  into  consideration.  One  of  the  most  complete 
available  studies  of  the  factor  of  race  is  that  for  New 
York  State.  The  following  table  compares  the  num- 
bers of  native  and  foreign-born  mothers  resorting  to 
midwives:  ^ 

TABLE  XXVI 

Births  Attended  by  Midwives  in  New  York  State,  According 
TO  THE  Nativity  of  the  Mothers  (New  York  City  Ex- 
cluded), 1916 


Nativitt  of  Mother 


Native,  white 

Foreign  born,  white 

England,  Scotland,  Wales .... 

Ireland 

Germany 

Italy 

Russia 

Austria-Hungary 

Poland  (includes  German,  Aus 
trian,  and  Russian  Poles).. . 

Canada 

Other  foreign  born 


Total 

BlETHS 


64,889 
37,914 

1,869 
1,879 
2,296 
12,998 
3,665 
6,345 

4,703 
2,219 
1,940 


BiETHS  Attended 
BY  Midwives 


Number 


2,504 

14,165 

28 

29 

633 

5,276 

1,174 

3,630 

3,112 

44 

239 


Per  Cent  of 
Total  Births 


3.9 
37.3 

1.5 
1.5 
27.6 
40.6 
32.0 
57.2 

66.1 

2.0 

12.3 


The  difference  in  the  proportionate  use  of  midwives 
by  native  and  by  foreign-born  mothers  is  the  out- 
standing fact  of  the  table.  It  is  not  possible,  however, 
to  lump  the  foreign-born  mothers  together  in  the 
generalization  that  they  all  have  midwives.     The 

1  Thirty-seventh  Annual  Report,  New  York  State  Department  of 
Health,  1916,  p.  454,  Table  VII. 

14  1^^ 


IMMIGRANT  HEALTH  AND  COMMUNITY 

per  cent  of  those  who  do  varies  among  the  races 
from  66.1  for  the  Poles  to  1.5  for  the  English-speaking 
foreign  born,  a  rate  that  falls  below  that  of  the 
native  born.  The  high  per  cent  for  native-born 
mothers  is  probably  explained  by  the  fact  that 
women  of  native  birth  employing  midwives  "were 
of  Italian,  Russian,  or  Austro-Hungarian  parentage, 
and  .  .  .  the  custom  of  the  native  country  of  their 
parents  still  held  considerable  sway." 

A  study  of  mothers  in  New  York  City  found  56.2 
per  cent  using  midwives;  87  per  cent  of  those  using 
midwives  were  foreign  born;^  and  58  per  cent  of 
those  foreign  born  were  Italian.  The  use  of  mid- 
wives  by  Italian  mothers  is  everywhere  prevalent. 
In  one  study  of  two  hundred  and  eighty-nine  Italian 
deliveries,  91.7  per  cent  were  attended  by  midwives.^ 
A  study  of  three  cities  in  California  showed  that 
"the  midwifery  situation  ...  is  very  largely  confined 
to  the  foreign-born  population,  principally  Italian 
and  Japanese."  ^  From  Chicago,  Detroit,  and  Penn- 
sylvania studies  come  similar  findings.^    The  foreign- 

1  Jacob  Soble,  M.D.,  "Instruction  and  Supervision  of  Ex- 
pectant Mothers  in  New  York  City."  Reprint  from  New  York 
Medical  Journal,  January  19,  1918,  pp.  16,  17. 

2  Compiled  from  material  received  from  the  Bureau  of  Educational 
Nursing,  Association  for  the  Improvement  of  the  Condition  of  the 
Poor,  New  York  City,  1918. 

3  Mrs.  Elwyn  Stebbins,  "Supplementary  Report  on  the  Mid- 
wives  of  Oakland,  Alameda,  and  Berkeley,"  Sixth  Annual  Report 
of  the  American  Association  for  the  Study  and  Prevention  of  Infant 
Mortality,  pp.  149-150. 

*  Report  of  the  Health  Insurance  Commission  of  the  State  of  lU 
linois.  May  1, 1920,  p.  60.  "  How  Two  Thousand  Detroit  Mothers 
Were  Cared  for  in  Childbirth,"  Detroit  Home  Nursing  Association, 
Detroit,  1917,  pp.  1,  3,  6.  Emma  Duke,  "Infant  Mortality,  Johns- 
town, Pennsylvania,"  Children's  Bureau,  United  States  Department 
of  Labor,  1915,  p.  60,  Table  IV. 

198 


THE  MIDWIFE 

born  mothers,  especially  among  the  Italian  and 
Slavic  peoples,  have  not  the  habit  of  using  physicians. 
Were  there  no  foreign-born  mothers  there  would  be 
practically  no  midwife  problem. 

REASONS    FOR    USING    THE   MIDW^FE 

The  reasons  why  the  foreign  born  use  midwives  so 
extensively  are  easy  to  understand  from  the  facts  of 
their  background  and  their  usual  circumstances  in 
this  country. 

One  reason  is  the  prejudice  against  having  a  man 
doctor.  We  hear  much  of  the  so-called  sex  prejudice 
of  the  foreign-born  woman  in  this  respect.  There  is 
no  doubt  that  it  exists  to  a  greater  or  less  degree, 
depending  on  the  race  and  the  individual.  The  hus- 
band, also,  has  a  large  part  in  determining  whom  the 
woman  shall  have  and  how  much  shall  be  paid. 
When,  as  is  likely,  he  does  not  know  any  doctors,  he 
must  be  brought  to  feel  absolute  confidence  in  a  new 
and  more  expensive  kind  of  service.  He  must  be 
persuaded  to  let  a  strange  man  doctor  render  very 
intimate  services  to  his  wife,  for  he  cannot  usually 
afford  a  woman  attendant  also.  There  is  reason  to 
believe  that  the  prejudice  is  sometimes  given  as  an 
excuse  for  having  a  midwife  when  the  real  reason  is 
economic,  or  simply  strongly  rooted  custom. 

Another  reason  for  using  the  midwife  is  the  tra- 
dition of  capability  carried  over  from  foreign  coun- 
tries wherein  these  women  have  recognized  profes- 
sional status.  Throughout  Europe  the  midwife  is  a 
highly  specialized  trained  person.  In  Holland,  Bel- 
gium, France,  and  Italy,  a  full  two  years*  course  of 
training  is  required  before  a  woman  may  practice 

199 


IMMIGRANT  HEALTH  AND  COMMUNITY 

midwifery.  In  Norway,  Sweden,  Denmark,  and 
England  the  course  is  one  year.  In  Germany  she 
gets  six  months'  training  in  government  clinics,  under 
university  professors.  In  most  countries  abroad, 
moreover,  the  midwives  are  licensed  and  are  care- 
fully supervised  by  the  state. ^  The  mother  may  have 
already  used  midwives  and  known  many  of  them 
through  her  friends  abroad.  The  immigrant  family 
has  many  reasons  for  implicit  trust  in  the  midwife. 

The  immigrants'  chief  reason  for  using  the  mid- 
wife, however,  is  economic.  The  midwife  costs  less 
than  the  physician,  both  because  her  fee  is  lower  and 
because,  even  when  she  does  little  housework,  she 
renders  more  service  to  the  mother  and  the  family 
than  the  physician  does.  Many  midwives  do  not 
only  the  actual  obstetrical  work  in  confinement,  but 
a  large  amount  of  housework,  thus  greatly  assisting 
the  mother  of  a  family  of  children  to  get  through  a 
very  trying  period.  This  has  been,  and  still  is,  a 
distinct  element  in  deciding  many  immigrant  fam- 
ilies in  favor  of  the  midwife  as  against  the  doctor. 

A  good  deal  of  evidence  is  accumulating,  however, 

to  the  effect  that  the  midwife  is  doing  less  housework 

than  formerly.     The  head  nurse  of  the  system  of 

supervising  midwives  in  a  large  city  said  that  the 

better  t»rained  the  midwife  was  the  less  housework 

she  now  did.     The  shortage  of  doctors  during  the 

war  undoubtedly  enabled  many  midwives  to  reduce 

the  amount  of  their  housework  and  not  lose  clientele. 

1  See  "The  Midwife  in  England,"  by  Miss  Carolyn  Van  Blarcom, 
and  "Schools  for  Midwives,"  by  Dr.  S.  Josephine  Baker,  in  the 
Proceedings  of  the  Second  Annual  Meeting  (1911)  of  the  American 
Association  for   the   Study   and   Prevention   of  Infant   Mortality, 

p.  232,  seq. 

200 


THE  MIDWIFE 

The  material  gathered  by  the  Association  for  the 
Improvement  of  the  Condition  of  the  Poor,  covering 
the  period  1912  to  1919,  shows  this  tendency  over  a 
longer  period,  and  adds  considerable  weight  to  the 
belief  that  the  housework  done  by  the  midwife  is 
decreasing.  Of  two  hundred  and  eighty-nine  cases 
having  midwives,  96.2  per  cent  of  the  midwives  did 
not  do  any  housework. 

Midw^ives'  fees  are  invariably  lower  than  doctors'. 
The  Detroit  Maternity  Survey,  already  mentioned, 
found  that 

...  in  the  cases  in  which  the  doctor  employs  a  practical 
nurse  to  visit  his  maternity  patients  he,  as  a  rule,  makes 
but  one  visit.  The  nurse  makes  on  an  average  of  six, 
and  the  common  charge  for  the  combined  services  is  $20. 
The  patient  in  such  cases  is  left  to  the  care  of  a  child  or  a 
neighbor  for  the  greater  part  of  the  time.  The  neighbor  is 
often  paid.  Midwives'  charges  ranged  from  $7  to  $10  for 
services  at  the  birth  and  visits  daily  for  five  days  or  more. 
A  few  cases  are  recorded  in  which  the  charge  was  but  $5. 
In  the  majority  of  cases  the  charge  was  $10.  Doctors' 
charges  ranged  from  $10  to  $30.  The  higher  figure  was  not 
as  frequently  found  as  was  the  charge  of  $1.5.  Twenty- 
dollar  or  $25  fees  to  doctors  were  found  in  most  cases.^ 

In  California  rates  for  midwives  are  found  to  be 
higher  than  in  Detroit,  but  in  California  medical  fees 
are  also  higher.  Dr.  Adelaide  Brown,  in  a  report^ 
dated  1915,  found  that 

^"How  Two  Thousand  Detroit  Mothers  Were  Cared  for  in 
Childbirth,"  Detroit  Home  Nursing  Association,  Detroit,  1917, 
p.  12. 

2  Dr.  Adelaide  Brown,  "A  Report  of  the  Midwife  Situation  in 
San  Francisco  and  Alameda  Counties,  California,"  with  supple- 
mental report  by  Mrs.  Elwyn  Stebbins,  Sixth  Annual  Report  of 
American  Association  for  Study  and  Prevention  of  Infant  Mor- 
tality, pp.  147-150. 

201 


IMMIGRANT  HEALTH  AND  COMMUNITY 

.  .  .  the  average  fee  [was]  $15  to  $20,  some  taking  $10 
when  they  cannot  get  $20  or  $15.  ...  Of  33  midwives  in 
the  1913-14  Ust  registering  80  per  cent  of  births  recorded 
by  midwives,  only  13  record  over  30  [births]  each  at  $15 
apiece.  Thirty  births  give  an  annual  income  of  $540,  and 
$416  ($8  a  week)  is  considered  the  minimum  wage. 

The  fee  included  daily  nursing  care  for  mother  and 
child  for  from  ten  to  fourteen  days. 

The  Association  for  the  Improvement  of  the  Con- 
dition of  the  Poor  in  New  York  City  made  a  tabula- 
tion of  two  hundred  and  eighty-five  deliveries  of 
Italian  women  during  the  years  1912-19.^  From 
their  data  the  following  table  was  constructed: 

TABLE  XXVII 

Fee  Rates  for  Delivery  of  285  Cases,  New  York  City, 

1912-19 


NuMBEE  OF  Cases  Deliveked  by 

Charges 

Midwives 

Doctors 

Midwife  and 
Doctor 

$  l-$5 

7 

49 

25 

16 

54 

1 

81 

2 

4 

3 

2 

20 

1 

2 

4 

1 

2 
6 

5 

6 

7 

8 

9 

10 

11 

12 

13 

15 

Over  $15 

3 

Free 

2 

Total 

264 

16 

5 

^  Data  furnished  by  the  Association  for  the  Improvement  of 
the  Condition  of  the  Poor. 

202 


THE  MIDWIFE 

Information  kindly  furnished  by  Dr.  S.  Josephine 
Baker,  Director  of  the  Bureau  of  Child  Hygiene  of 
the  New  York  City  Department  of  Health,  sub- 
stantiates these  figures.  The  data  show  that  mid- 
wives'  rates  vary  between  $5  and  $25.  Differences 
appear  in  different  parts  of  the  city,  the  rate  becom- 
ing somewhat  higher  as  we  proceed  "uptown"  in 
Manhattan.  The  great  bulk  of  the  midwives  in 
Manhattan  charge  $10.  In  the  Bronx  and  Rich- 
mond, $15  is  a  more  frequent  charge  than  $10,  but 
more  than  $15  is  charged  in  only  a  small  proportion 
of  cases  anywhere. 

Of  course  many  immigrant  families  get  along  in 
this  country  and  improve  their  financial  status. 
When  there  is  not  the  urgent  economic  handicap, 
they  want  and  secure  for  themselves  and  their  fam- 
ilies the  best  care  and  attention  in  time  of  sickness 
that  is  available.  Whether  this  can  be  secured 
through  the  midwife  is  the  question.  But  since  the 
midwife  is  not  only  preferred  by  a  considerable  pro- 
portion of  our  population  because  of  tradition  and 
training,  but  is  often  the  only  agency  economically 
possible,  she  is  inevitably  influencing  the  health  and 
future  of  many  young  Americans. 

STATUS   OF   THE   AMERICAN   MIDWIFE 

Midwifery  in  America  is  at    present  sadly  imstand- 

ardized.    The  best  typ^  of  midwife  is  the  woman  who 

received  her  training  abroad  and  who  takes  up  the 

work  as  a  definite  vocation.     We  also  find  many 

examples  of  the  casual  midwife,  the  woman  who  has 

had  no  training  except  experience  with  her  own  and 

203 


IMMIGRANT  HEALTH  AND  COMMUNITY 

her  neighbors'  children.  When  her  family  of  young- 
sters have  grown  old  enough  for  her  to  leave  them 
she  gives  part  of  her  time  to  helping  her  neighbors, 
and  earns  a  certain  amount  of  money  at  the  same 
time. 

Although  several  states,  such  as  New  Jersey,  Ohio, 
and  Wisconsin,  require  midwives  by  law  to  be  trained 
before  obtaining  licenses,  none  of  them  has  any 
recognized  school  for  teaching  midwifery.  A  large 
number  of  commercial  schools  exist  whose  adver- 
tisements may  be  found  in  not  a  few  foreign-language 
newspapers.  Most  of  these  appear  to  give  wholly 
inadequate  training  and  some  are  undoubtedly  mere 
diploma  mills. 

The  Bellevue  Hospital  School  of  Midwifery,  in 
New  York,  is  the  only  school  in  this  country  under 
public  control,  which  is  in  this  case  municipal.  This 
school  is  under  the  direction  of  the  Superintendent 
of  Nurses.  No  special  requirements  are  necessary 
for  entrance.  The  applicant  must  be  twenty-one 
years  of  age,  be  able  to  read  and  write,  and  be  of 
good  moral  character.  No  fee  is  charged  for  the 
course  of  eight  months,  during  which  the  students 
live  in  the  school.  There  are  nineteen  beds  for 
maternity  cases,  as  well  as  an  out-patient  depart- 
ment. Each  pupil  must  have  attended  one  hundred 
cases,  and  herself  conducted  twenty  confinements, 
before  receiving  her  certificate.  Up  to  the  time  of 
writing  (1919)  no  graduate  nurses  have  taken  the 
course  in  the  Bellevue  Hospital  training  school  for 
midwives.     The  superintendent  says: 

We  have  not  yet  anything  in  our  course  to  induce  trained 
nurses  to  enter  the  school.     The  course  is  too  simple. 

204 


THE  MIDWIFE 

The  number  of  graduates  from  this  school  was 
only  about  twenty-eight  in  1918-19.  Such,  at  pres- 
ent, is  the  status  of  training  for  midwifery  in  the 
United  States  of  America. 

The  legal  and  social  status  of  the  midwife  is  very 
different  in  this  country  and  abroad. ^  In  the  United 
States  the  midwife  has  been  a  declassed  person.  We 
have,  in  general,  provided  no  laws  regarding  her 
training,  licensing,  or  regulation.  Consequently  any 
woman,  whether  trained  or  ignorant,  conscientious 
or  unscrupulous,  may  take  up  midwifery. 

Only  recently  have  we  begun  to  recognize  the  mid- 
wife in  an  official  way.      Only  twenty-one  of  our 
forty-eight  states   have  laws  regulating  midwifery, 
but  in  many  of  these  the  laws  are  almost  valueless 
because    no    provision   for    enforcement    is   made. 
In  Massachusetts  and  Nebraska  the  midwife  cannot 
practice  legally.     In  thirteen  states  there  are  no  laws 
applying  at   all,  and  the  midwife  may  practice  for 
weal  or  woe.     They  are  Arizona,  Arkansas,  Florida, 
Georgia,  Idaho,  Kentucky,  Maine,  Mississippi,  New 
Mexico,  South  Carolina,  Tennessee,  Vermont,  West 
Virginia.     In  twelve  states  the  midwife  is  legally 
recognized,  but  there  are  no  general  laws  regulating 
her  training  or  practice.      They  are  Alabama,  Cali- 
fornia, Delaware,  Michigan,  New  Hampshire,  North 
Dakota,    Oklahoma,  Oregon,   Rhode  Island,   South 
Dakota,  Texas,  Virginia. 

In  thirteen  of  the  twenty-one  states  having  mid- 
wife regulations,  as  well  as  in  the  District  of  Colum- 

^We  owe  to  the  courtesy  of  Miss  Carolyn  C.  Van  Blarcom 
these  data  regardmg  state  and  municipal  legislation  on  midwifery, 
revised  up  through  the  year  1916. 

205 


IMMIGRANT  HEALTH  AND  COMMUNITY 

bia,  midwives  must  pass  an  examination  before 
receiving  a  state  license,  but  in  seven  of  these  the 
provision  for  enforcement  is  so  poor  as  to  make  the 
law  of  no  effect.  The  thirteen  are  Connecticut, 
Illinois,  Indiana,  Louisiana,  Maryland,  Minnesota, 
Missouri,  New  Jersey,  New  York,  Ohio,  Utah,  Wis- 
consin, Wyoming. 

Candidates  for  state  licenses  are  generally  exam- 
ined by  the  state  boards  of  midwifery,  appointed  by 
state  boards  of  health,  or  by  boards  of  medical  super- 
vision. Midwives  already  practicing  usually  can 
continue  to  do  so  jtist  by  registering. 

The  Illinois  state  law  has  a  strong  penalty  clause 
covering  the  midwives  who  fail  in  reporting  babies 
with  sore  eyes.  It  imposes  a  fine  of  $100  for  the  first 
case  and  $200  for  the  second  case,  or  six  months' 
imprisonment,  or  both. 

In  Omaha,  Nebraska,  we  find  that  25  per  cent  of 
all  births  registered  are  midwife  cases.  Under  the 
laws  of  Nebraska  a  midwife  may  be  prosecuted  for 
practicing  medicine  without  a  doctor's  license,  but 
there  is  a  city  ordinance  governing  the  Omaha  situa- 
tion. In  a  number  of  cities  we  find  midwives  prac- 
ticing under  local  ordinances.  Buffalo  was  the  first 
city  to  enact  such  a  law  some  forty- three  years  ago. 
Los  Angeles,  in  1910,  passed  a  law  by  which  midwives 
are  examined  and  licensed  by  the  city  Department 
of  Health. 

Virginia  is  one  of  the  twelve  states  with  no  general 

laws,  but  the  city  of  Norfolk  regulates  midwives 

under  an  ordinance  of  1912.    In  Norfolk  a  midwife 

is  required  to  register  and  be  licensed  by  the  Board 

of  Health,  and  to  notify  \t  within  ten  days  of  any 

206 


THE  MIDWIFE 

change  in  address,  yet  there  is  no  penalty  clause 
providing  for  failure  to  comply  with  the  law.  In 
Tennessee,  another  state  with  no  law,  Memphis  is 
working  under  a  city  ordinance  of  August  9,  1910, 
by  which  midwives  are  licensed  and  registered.  The 
license  is  good  for  one  year  and  can  be  renewed  an- 
nually. Memphis  invokes  a  fine  of  from  $5  to  $50 
for  midwives  found  practicing  without  a  license. 

The  system  of  supervision  of  midwives  in  the  city 
of  Newark,  New  Jersey,  may  be  briefly  described  as 
one  of  the  excellent  examples  of  the  best  type  of 
work.^  New  Jersey  has  a  compulsory  law,  but  the 
following  experience  indicates  how  much  farther  co- 
operative efforts  with  midwives  will  go  than  mere 
legal  pressure. 

When  our  bureau  was  organized  in  1913  to  protect  the 
health  and  prevent  disease  and  death  in  mothers  and 
infants  we  recognized  that  the  active  supervision  and  train- 
ing of  midwives  was  one  of  the  most  effective  methods  of 
obtaining  this  result,  since  the  midwives  in  Newark  attend 
50  per  cent  of  the  births  and  in  certain  groups  of  nationalities 
as  high  as  80  per  cent  and  90  per  cent. 

In  the  beginning  we  directed  oiu-  attention  to  interesting 
the  midwife  in  the  work  we  were  undertaking  for  the  pro- 
tection of  maternal  and  infant  life  in  the  belief  that  mid- 
wives  would  respond  to  the  appeal  as  well  as  other  members 
of  the  community.  The  midwives  were  asked  to  assist 
the  nurses  in  their  districts:  firstly,  by  reporting  promptly 
all  the  births;  secondly,  by  establishing  the  routine  of 
infant  care  and  breast  feeding,  which  would  later  be  taught 
by  the  nurse  when  she  visited  the  mother;  thirdly,  to 
advise  the  mother  that  the  nurse  would  visit  and  that  she 
should  welcome  and  accept  the  instructions  that  were  to 
be  given  to  her.     In  this  way  we  capitalize  the  influence 

^  Dr.  Julius  Levy  of  Newark,  New  Jersey,  memorandum  for  this 
study. 

207 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  midwives  had  with  the  foreign-born  mothers  and  at  the 
same  time  removed  the  initial  suspicion  that  the  Health 
Department  desired  to  interfere  with  their  practice  and 
eventually  to  eliminate  them  entirely.  A  booklet  was 
printed  in  the  various  languages  spoken  by  midwives,  which 
set  forth  not  only  the  legal  restrictions  on  the  practice  of 
midwives,  but  amplified  these  laws  so  that  they  could  not 
plead  a  lack  of  understanding  of  the  law  for  any  infraction 
of  it. 

I  may  illustrate  this  point,  which  I  consider  a  very 
important  factor  in  obtaining  results,  by  referring  to  the 
regulations  which  prohibit  midwives  from  assuming  care 
of  abnormal  cases.  Most  midwives  do  not  consider  con- 
ditions abnormal  that  are  at  all  frequent  or  that  they  feel 
themselves  competent  to  look  after.  By  this  method  we 
have  gradually  trained  the  midwives  to  consider  all  con- 
ditions that  we  think  require  special  medical  attention  as 
abnormal,  even  such  as  difficult  maternal  nursing,  or  the 
care  of  an  immature  infant. 

Later  we  adopted  the  practice  of  inviting  each  midwife 
for  a  special  interview  whenever  the  nurse  discovered  any 
condition  or  heard  of  any  practice  that  indicated  either 
carelessness,  ignorance,  or  excessive  activity  or  officiousness. 

This  gave  us  an  opportunity  to  explain  to  each  midwife 
individually  the  importance  of  reporting  all  births  and 
reporting  them  promptly  within  the  five-day  limit,  of 
sending  for  doctors  promptly  whenever  there  was  the  least 
abnormality  in  pregnancy  or  labor  or  infant,  of  explaining 
the  proper  technique  for  the  care  of  mother  and  infant. 

We  have  investigated  every  case  of  puerperal  death  to 
determine  if  a  midwife  attended  it  at  any  time.  In  each 
instance  the  midwife  was  asked  to  appear  before  us  so  that 
we  might  be  able  to  point  out  the  care  that  should  be  taken 
to  prevent  a  similar  fatality,  even  though  there  was  no 
evidence  that  the  midwife  was  responsible. 

In  the  beginning  we  did  not  attempt  to  fix  responsibility 
upon  the  midwife,  but  rather  gave  her  the  impression  that 
while  we  believed  all  she  said  in  regard  to  her  extreme 
precautions  and  aseptic  technique,  the  particular  death 

208 


THE  MIDWIFE 

showed  the  necessity  of  even  greater  care  and  precautions. 
This  same  method  has  been  followed  out  in  obtaining  reports 
of  ophthalmia,  the  use  of  silver  nitrate,  prompt  reporting  of 
births,  care  of  nipples  and  breasts,  and  the  prevention  of 
unnecessary  weaning. 

Even  when  our  reports  showed  that  the  midwives  were 
using  hypodermic  injections  of  pituitrin,  arsenic,  and 
strychnine  we  took  the  position  that  inasmuch  as  hereto- 
fore no  public  department  has  taken  any  interest  in  the 
work  or  exercised  any  supervision,  it  was  only  fair  that  they 
be  given  a  chance  to  adjust  themselves  to  the  new  condi- 
tions and  that  the  best  results  would  be  obtained  by  getting 
the  midwives  to  discontinue  this  practice  through  the 
proper  spirit  of  co-operation  and  appreciation  of  the 
dangers  of  this  practice  to  the  patient  and  to  the  midwife 
herself,  rather  than  by  proceeding  against  her  legally. 

When  we  discovered  that  a  certain  few  midwives  persisted 
in  this  type  of  practice  after  having  been  warned  several 
times  they  were  brought  up  on  charges  before  the  courts, 
and  in  several  instances  fined  in  accordance  with  our  city 
ordinance. 

A  lecture  course  was  arranged  which  was  given  by  the 
representative  physicians  of  the  city  on  obstetrical  work 
and  the  care  of  babies.  Demonstrations  of  the  preparation 
of  the  bed,  the  patient,  and  the  room  have  been  given  at 
the  City  Hospital  by  the  instructor  of  the  training 
school. 

The  effect  of  supervision  in  Newark  is  well  brought  out, 
perhaps,  by  the  statement  that  has  been  made  by  our 
county  supervisor  of  midwives,  who  learned  that  midwives 
who  carefully  conformed  to  the  best  standards  of  mid- 
wifery practice  and  legal  regulations  while  working  in 
Newark  would  frequently  become  neglectful  or  assume 
risks  when  their  patients  lived  outside  of  Newark. 

The  training  and  supervision  of  midwives,  not  mere  legal 
regulations  and  policing,  have  contributed  in  no  small  way 
to  the  very  gratifying  results  in  child  hygiene  in  Newark, 
where,  with  a  very  small  appropriation,  $20,000,  it  has  been 
possible  to  bring  the  infant  mortality  rate  for  the  first  six 

209 


IMMIGRANT  HEALTH  AND  COMMUNITY 

months  of  1919  to  77.6,  the  second  lowest  rate  for  the 
fourteen  largest  cities  in  the  United  States. 

If  such  supervision  is  well  conducted,  it  tends  to 
encourage  good  midwife  practice,  whereas  an  attempt 
to  ban  midwives  by  legislative  fiat  keeps  the  best 
ones  out  of  the  state,  as  in  Massachusetts,  and  leaves 
the  practice  chiefly  to  the  ill-trained  and  unscrupu- 
lous, who  work  in  spite  of  the  law. 


QUALITY    OF   AMERICAN   MIDWIFERY 

The  quality  of  the  midwife's  work  may  be  judged  in 
comparison  with  an  ideal  standard  or  with  other 
forms  of  obstetrical  care  available  to  the  poor. 
Naturally,  those  who  have  looked  at  the  midwife 
from  the  top  down,  and  those  who  have  looked  at 
her  from  the  bottom  up,  are  likely  to  disagree  as  to 
the  reality.  Some  have  judged  her  by  the  standard 
of  obstetrical  service  actually  maintained  by  special- 
ists in  the  homes  of  their  patients,  or  by  maternity 
hospitals  of  the  first  class.  For  instance,  Doctors 
Emmons  and  Huntington,  in  their  vigorous  attack 
on  the  midwife,^  compare  her  work  with  "the  mini- 
mum amount  of  care  which,  in  the  light  of  modern 
medicine,  it  is  fair,  right,  and  humane  to  offer." 

Few  have  been  ready  to  compare  the  work  of  the 
average  private  physician  with  the  same  standard. 
It  is  well  that  this  is  not  done,  for  the  comparison  is 
fair  to  neither  midwife  nor  physician.     Neither  is 

1  A.  B.  Emmons,  2d,  M.D.,  and  J.  L.  Huntington,  M.D.,  "Has 
the  Trained  and  Supervised  Midwife  Made  Good?"  Proceedings 
of  Second  Annual  Meeting  (1911)  of  American  Association  for  the 
Study  and  Prevention  of  Infant  Mortality,  pp.  199-213. 

210 


THE  MIDWIFE 

provided  with  the  facilities,  financial  or  professional, 
which  the  highly  paid  specialist  has  at  his  command 
in  the  homes  of  the  wealthy  or  in  well-organized 
maternity  hospitals  and  out-patient  services.  Com- 
paring the  actual  results  of  midwifery  with  the 
sum  total  of  obstetrical  practice,  the  midwife  has 
been  shown  to  be  doing  a  relatively  good  grade  of 
work. 

This  point  of  view  is  amply  expressed,  both  in 
correspondence  carried  on  during  the  study  and  in 
published  material.  A  nurse  of  high  standing,  occu- 
pying an  important  supervisory  position  in  a  large 
industrial  center  of  the  East,  speaks  as  follows : 

At  present  the  midwives  are  teaching  me.  Many  of 
them  are  well-educated,  thoroughly  trained  women.  The 
Italian  midwife  is  an  unusually  well-educated  woman, 
ranking  next  to  the  priest  in  many  Italian  communities. 
In  Italy  none  but  a  well-educated  woman  can  qualify  for 
the  training,  which  covers  from  two  to  four  years.  The 
Italian  midwife  is  a  splendid  woman,  with  a  fine  viewpoint, 
and  desires  to  be  of  service.  They  are  well-trained,  scien- 
tific women,  recognizing  the  value  of  inspection  and  super- 
vision, to  which  they  have  always  been  accustomed  in 
Italy,  and  welcoming  it  when  they  find  it  in  America. 
They  are  so  thoroughly  well  trained  and  taught  that 
never  under  any  circumstances  will  they  try  to  handle 
unusual  conditions,  but  immediately  will  call  in  a  physician. 

A  physician  occupying  a  position  in  one  of  the 
largest  state  departments  of  health  in  the  country 
writes : 

I  have  observed  good  and  adequate  care  rendered  by 
midwives.  Many  of  them  have  been  trained  in  the  great 
schools  abroad,  and  these  women  are  very  expert  and  do 
excellent  work.    Several  midwives  under  our  supervision 

211 


IMMIGRANT  HEALTH  AND  COMMUNITY 

have  undergone  periods  of  training  as  high  as  four  years 
abroad,  including  such  training  as  would  be  equivalent  to, 
if  not  better  than,  some  received  by  some  American  nurses. 
Of  course  the  variety  of  ability  on  the  part  of  the  midwives 
varies  from  such  skilled  service  to  what  is  doubtless  only 
very  superficial  ability. 

A  well-known  physician  ^  in  charge  of  an  important 
bureau  in  a  city  department  of  health  furnishes  a 
statement  of  interest  in  this  connection: 

We  have  been  supervising  our  midwives  for  four  years, 
during  which  time  they  have  handled  from  5,414  to  5,696 
births  per  year.  Thirty  per  cent  of  all  midwives  are 
German,  21  per  cent  Italian,  21  per  cent  Austrian,  and  the 
remainder  Russian,  Polish,  and  Armenian.  If  the  midwife 
is  the  cause  of  much  infant  mortality  we  should  have  a 
high  infant  mortality  rate,  for  50  per  cent  of  all  births 
and  88  per  cent  of  all  foreign-born  mothers  are  attended 
by  midwives.  The  maternal  mortality  in  our  city  among 
midwife  cases  is  no  higher  than  in  the  city,  as  a  whole.  In 
order  to  get  exact  data  we  followed  up  until  one  month 
after  birth  586  mothers  delivered  by  midwives,  and  in 
this  group  one  mother  died.  When  we  recall  that  midwives 
attend  as  much  as  88  per  cent  of  our  foreign-born  groups 
living  in  congested  quarters  there  seems  to  be  little  ground 
for  the  charge  of  high  maternal  mortality  among  the 
women  in  our  city. 

An  article  by  Dr.  Charles  V.  Chapin,^  recently 
published  by  the  Federal  Children's  Bureau,  says: 

Last  year  10  per  cent  of  physicians'  reports  were  late 
and  only  1  per  cent  of  the  midwives'.  .  .  .  No  wonder  that 
in  Providence,  in  1917,  the  infant  mortality  rate  of  mid- 
wives'  babies  was  77,  while  of  all  others  it  was  117.  It 
cannot  be  argued  that  this  is  because  the  midwives  care 

^  Dr.  Julius  Levy  of  Newark,  New  Jersey. 
2  Dr.  Charles  V.  Chapin,  "The  Control  of  Midwifery,"  Standards 
of  Child  Welfare,  Children's  Bureau,  1919,  pp.  157-160. 

212 


THE  MIDWIFE 

for  a  stronger  stock  of  women  and  healthier  babies.  About 
85  per  cent  of  the  midwives'  babies  are  of  Italian  mothers. 
In  the  years  1902-09,  before  there  was  any  instructive 
nursing  service  for  mothers,  the  infant  mortality  rate  among 
Italians  was  138.     In  1917  it  was  93. 

Under  control  .  .  .  midwives  are  not  dangerous  to  the 
babies,  as  is  shown  by  the  Providence  figures.  .  .  .  That 
they  are  not  dangerous  to  the  mother  is  indicated  by 
data  from  Philadelphia,  where  there  were  only  17  deaths  in 
about  12,000  confinements  attended  by  supervised  midwives. 

A  similar  opinion  of  the  midwife  comes  from  the 
Department  of  Health  of  Newark,  New  Jersey } 

The  results  obtained  from  prenatal  supervision  of  mothers 
(by  the  Division  of  Child  Hygiene)  has  been  particularly 
satisfactory.  .  .  .  The  division  has  continued  its  policy 
of  supervising  the  midwives  in  the  city  and  has  received 
very  hearty  co-operation  from  the  midwives  themselves. 
There  is  no  doubt  that  they  are  sending  for  physicians 
more  frequently  in  difficult  labors  and  are  advising  the 
mothers  more  properly  in  the  care  of  the  infants  in  most 
instances. 

From  a  study  of  maternal  and  infant  mortality  among 
mothers  attended  by  midwives  it  would  appear  that  the 
results  are  very  commendable.  We  investigated  forty-one 
puerperal  deaths  reported  by  physicians  to  determine  if 
there  was  any  foundation  for  the  impression  that  puerperal 
deaths  that  occurred  in  the  hospitals  or  in  the  practice  of 
physicians  are  often  the  result  of  midwifery  incompetence, 
ignorance,  and  neglect,  the  cases  being  referred,  it  is  claimed, 
to  hospitals  and  physicians  when  all  the  mischief  has  been 
done.  Of  the  forty-one  cases  it  developed  that  in  only 
ten  had  a  midwife  been  in  attendance  at  any  time,  and  in 
no  instance  did  the  doctor  claim  that  the  midwife  was  in 
any  way  responsible  for  the  result. 

The  maternal  death  rate  in  Newark  is  one  of  the  lowest 


1  Annual   Report   of  the   Department   of  Health,   Newark,   New 
Jersey,  1917,  pp.  152-153. 
15  213 


IMMIGRANT  HEALTH  AND  COMMUNITY 

in  the  large  cities  of  the  United  States,  although  midwives 
attend  50  per  cent  of  the  births  of  the  city.  .  .  .  The  infant 
mortality  is  lowest  among  the  babies  whose  mothers  are 
attended  by  midwives  (as  the  following  table  shows): 


TABLE  XXVIII 

Death  Rates  per  1,000  Births  for  Infants  Attended  at  Birth 
BY  Midwives,  Physicians,  and  Hospitals,  1915-16-17 


Cases  Delivered 

Rates 

By  midwives 

71.2 

By  physicians 

80.4 

In  hospitals 

91  0 

In  considering  this  fact  it  should  be  pointed  out  that 
the  midwives  attend  a  smaller  proportion  of  primipara 
(first  births)  than  physicians  or  hospitals. 

Dr.  Abraham  Jacobi/  in  an  address  as  president 
of  the  American  Medical  Association,  declared: 

The  results  of  midwife  practice  do  not  always  compare 
unfavorably  with  those  of  our  professional  brethren.  Of 
116  cases  of  ophthalmia  neonatorum  which  were  treated  in 
the  Massachusetts  Eye  and  Ear  Infirmary  in  one  year, 
114  were  in  infants  attended  by  physicians,  and  two  by 
midwives.  Of  33  cases  treated  in  the  New  York  Eye  and 
Ear  Infirmary  in  one  winter  22  occurred  in  the  practice  of 
physicians  and  11  in  that  of  midwives.  Of  the  11  midwives, 
3  had  used  nitrate  of  silver;  of  the  22  doctors,  only  1. 
According  to  these  reports,  if  it  were  wise  and  proper  to 
generalize,  the  doctors  should  be  replaced  by  midwives. 

Dr.  J.  Whitridge  Williams,  in  an  authoritative 
survey  of  the  teaching  and  practice  of  obstetrics  in 

'^Dr.  Abraham  Jacobi,  "The  Best  Means  of  Combating  Infant 
Mortality,"  Journal  oj  the  American  Medical  Association,  June  8, 
1912,  pp.   1740-1744. 

214 


THE  MIDWIFE 

the  United  States  in  1910,  asked  the  teachers  of  ob- 
stetrics in  the  medical  schools  of  the  country  a  num- 
ber of  questions.  Among  them  was  the  following, 
which  is  quoted  with  its  answer  and  with  Doctor 
Williams's  summary.^ 

Do  you  believe  that  more  women  die  from  puerperal 
infection  and  eclampsia  in  the  practice  of  midwives  or  of 
general  practitioners? 

To  this  8  teachers  replied  that  they  did  not  possess 
sufficient  data  upon  which  to  base  an  opinion;  while  of 
the  35  who  answered,  17  stated  physicians  and  13  mid- 
wives,  while  5  held  that  their  death  rate  is  about  equal. 

Accordingly,  it  appears  that  the  majority  of  teachers 
in  this  country  consider  that  general  practitioners  lose  as 
many  and  possibly  more  women  from  puerperal  infection 
than  do  midwives.  This  is  an  appalling  conclusion,  as  it  is 
generally  believed  that  infection  is  the  main  cause  of 
preventable  deaths  in  the  practice  of  the  latter.  It  may, 
however,  be  mitigated  to  some  extent  by  admitting  that  the 
more  serious  cases  of  infection  occurring  in  the  hands  of 
midwives  are  eventually  seen  by  physicians,  so  that  their 
death  is  not  credited  to  the  former;  but  even  after  making 
such  allowances,  it  is  impossible  to  escape  the  conclusion 
that  such  a  condition  of  affairs  is  a  railing  indictment  of  the 
average  general  practitioner  and  of  our  methods  of  obstetri- 
cal instruction. 

The  conclusion  reached  by  Doctor  Williams  does 
not  seem  to  have  been  shaken  by  subsequent  inves- 
tigations or  criticisms.  Our  interest,  however,  is 
much  less  in  making  a  comparison  between  the  mid- 
wife and  the  medical  practitioner  than  in  considering 
the  midwife  herself,  as  an  agent  of  maternity  service 

ij.  Whitridge  Williams,  M.D.,  "The  Midwife  Problem  and 
Medical  Education  in  the  United  States,"  Report  of  Second  Annual 
Meeting,  American  Association  for  Study  and  Prevention  of  Infant 
Mortality,  1911,  pp.  165-194. 

215 


IMMIGRANT  HEALTH  AND  COMMUNITY 

to  foreign-born  mothers  in  this  country.  The  con- 
clusions reached  as  a  result  of  practical  experience 
by  departments  of  health,  physicians,  and  nurses, 
are  not  arguments  that  we  should  be  satisfied  with  the 
midwife  as  the  means  of  obstetrical  service  for  the 
people,  whether  foreign  or  native  born.  They  are 
evidence  that  competent  professional  men  and 
women  who  have  had  actual  experience  rate  the 
work  of  certain  types  of  midwives  as  of  excellent 
grade. 

An  impartial  look  at  the  midwife  situation  brings 
out  some  important  facts.  It  must  be  recognized 
that  our  knowledge  of  midwifery  in  the  United  States 
is  limited.  Statements  from  the  many  communities 
in  which  there  is  no  official  regulation  and  supervi- 
sion of  midwives  cannot  represent  the  whole  situation. 

The  facts  reported  from  communities  in  which 
midwives  are  regulated  and  supervised,  and  in  which, 
therefore,  the  whole  body  of  midwife  work  is  more 
or  less  well  known,  demonstrate  that  a  certain  pro- 
portion of  midwives  provide  at  least  as  good  care 
as  any  other  which  the  mass  of  the  people  can  pay 
for  on  a  business  basis.  On  the  other  hand,  there 
is  a  certain  proportion  of  midwives  whose  work  is 
below  any  acceptable  standard. 

While  we  cannot,  therefore,  make  a  sweeping  judg- 
ment either  way  of  the  quality  of  midwives'  work, 
we  can  point  out  certain  intrinsic  limitations  that 
will  prevent  her  from  ever  being  a  wholly  satisfactory 
instrument  of  maternity  care. 

Most  important,  the  midwife  cannot  herself  pro- 
vide certain  elements  essential  to  a  good  standard  of 

maternity  care.    She  cannot  furnish  expert  obstetri- 

216 


THE  MIDWIFE 

cal  diagnosis,  nor  give  expert  supervision  and  advice 
during  pregnancy,  nor  provide  for  obstetrical  emer- 
gencies at  the  time  of  confinement. 

This  difficulty  might  be  overcome  if  the  midwives 
could  be  made  part  of  a  system  in  which  their  de- 
ficiencies were  supplied  by  the  work  of  expert  obstet- 
ricians; but  it  would  be  impossible  so  to  organize 
the  midwives  who  are  practicing  in  this  country 
to-day,  owing  to  their  wide  variations  in  quality. 
Much  of  midwifery  is  casual  work,  taken  up  by 
women  who  have  had  little  training  except  experi- 
ence with  their  own  or  their  neighbors'  children. 
The  work  of  these  women  is  usually  of  an  impossibly 
low  grade.  Real  supervision  and  the  maintenance 
of  a  high  standard  would  keep  the  best  within  the 
system  and  eliminate  the  worst  of  those  who  now 
practice  midwifery,  but  the  number  left  would  not 
be  adequate  for  the  work,  and  in  order  to  recruit 
new  midwives  of  the  grade  of  those  who  have  come 
from  Europe,  the  status  of  the  profession  must 
be  raised  materially. 


XI 

ADEQUATE  MATERNITY  CARE 

While  it  is  true  that  the  newest  immigrants  turn  to 
the  midwife  automatically,  there  is  some  evidence 
that  with  longer  residence  in  this  country  the  foreign 
born  naturally  forsake  the  midwife. 

In  the  article  previously  quoted,  Dr.  Charles  V. 
Chapin  said: 

There  is  evidence  to  show  that  midwifery  is  decreasing. 
Doctor  Woodward  stated  that  in  the  District  of  Columbia 
between  1896,  the  date  of  the  adoption  of  the  law  regulating 
midwives,  and  1915  the  number  of  births  attended  by 
midwives  in  the  District  of  Columbia  fell  from  50  per  cent 
of  the  total  births  to  less  than  10  per  cent.  In  1918  it 
was  5.5  per  cent.  This  was  due  chiefly  to  the  elimination 
of  midwives  by  examination.  In  New  York,  in  1905,  42.1 
per  cent  of  all  births  were  attended  by  midwives,  while  in 
1917  the  per  cent  was  33.5.  The  decrease  has  been  especially 
rapid  since  the  opening  of  the  war,  which  is  interpreted 
as  indicating  that  it  is  the  newcomers  who  are  most  inclined 
to  rely  upon  the  midwife.  In  Providence  the  proportion  of 
births  attended  by  midwives  increased  with  the  increasing 
tide  of  Italian  immigration  up  to  1913,  when  more  than 
33  per  cent  of  all  births  were  attended  by  them.  In  1918 
the  percentage  was  27.5.  In  Providence  there  has  been  an 
almost  complete  disappearance  of  the  Jewish  midwife. 
Ten  years  ago  nearly  150  births  annually  were  attended  by 
Jewish  midwives.  Last  year  there  were  but  4  so  attended, 
although  we  have  a  Jewish  population  of  nearly  20,000. 
This  seems  to  be  due  largely  to  the  appreciation  on  the  part 

218 


ADEQUATE  MATERNITY  CARE 

of  Jewish  women  of  the  value  of  medical  service.  In 
Rochester  the  number  of  midwives  and  the  number  of 
births  attended  by  them  has  decreased  during  the  last 
eight  or  ten  years. 

If  we  would  hasten  the  displacement  of  the  present 
midwife's  practice,  we  must  provide  substitutes  that 
will  be  understood  by  and  acceptable  to  the  people 
who  now  use  midwives  most  extensively.  To  over- 
come the  traditional  reason  for  selecting  the  midwife, 
and  the  so-called  sex  prejudice  against  a  man  doctor, 
is  a  matter  of  education.  The  economic  reason  for 
using  the  midwife  cannot  be  directly  overcome  by 
education,  although  people  will  often  pay  more  if 
they  feel  sure  that  by  so  doing  they  w411  get  some- 
thing much  better.  So  many  of  our  immigrant  fam- 
ilies live  under  severe  economic  pressure,  where  every 
dime  must  count,  that  a  new  maternity  service  can- 
not cost  much  more  than  the  midwife  if  it  is  to  be 
readily  used,  and  at  least  as  much  convenience  to 
the  family  at  the  time  of  confinement  is  to  be 
assured. 

When  the  immigrant  looks  about  for  a  substitute 
for  the  midwife,  he  finds  the  private  physician  and 
certain  organized  medical  resources — the  maternity 
hospital,  the  out-patient  system  of  maternity  care, 
and  various  clinics.  The  Maternity  Center  Associa- 
tion of  New  York  estimated  that  in  the  year  1917, 
midwives  cared  for  about  40  per  cent  of  the  total 
number  of  births  in  the  entire  city;  that  about  30 
per  cent  were  cared  for  by  the  out-patient  system 
of  maternity  care,  plus  the  maternity  hospitals 
themselves — that  is,  by  an  organized  maternity  care 
system.    The  remaining  30  per  cent  of  confinements 

219 


IMMIGRANT  HEALTH  AND  COMMUNITY 

were  cared  for  by  private  physicians.  The  propor- 
tion of  cases  receiving  care  through  an  organized 
system  of  hospital  and  maternity  out-patient  de- 
partments is  larger  in  New  York  City  than  perhaps 
anywhere  else  in  the  country. 

In  most  communities  the  only  available  substitute 
for  the  midwife  at  the  present  time  is  the  private 
doctor.  We  have  seen  some  of  the  reasons  why 
many  immigrant  families  will  employ  a  private  doc- 
tor at  the  time  of  the  mother's  confinement  only 
with  reluctance,  or  only  in  an  emergency. 

The  doctor  often  does  not  speak  the  language  of 
the  family.  He  charges  more;  he  renders  less  serv- 
ice. Does  he  give  better  service  from  the  point  of 
view  of  the  immigrant  family?  A  Jewish  woman 
said  to  an  American  visitor,  speaking  of  the  doctor 
and  the  midwife:  "The  doctor,  even  the  professor 
doctor,  he  comes  to  your  house  to  get  your  baby. 
He  hurries  you  up;  he  hurries  you  up;  he  hurries 
you  up,  and  that  is  not  so  good.'*  What  Dr.  Whit- 
ridge  Williams  says  in  the  article  quoted  in  the  last 
chapter  about  the  inadequate  teaching  of  obstetrics 
and  the  inadequate  training  of  the  average  practi- 
tioner for  this  work,  is  not  known  by  the  immigrant 
mother,  but  she  and  her  friends  have  felt  some  of  its 
results.  If  the  fee  that  they  pay  the  doctor  is  so 
low  that  he  can  or  will  give  them  only  very  little 
time,  and  hurries  them  up,  and  uses  forceps  to  take 
the  baby,  they  may  make  a  comparison  with  what 
the  midwife  will  do  for  them  to  the  advantage  of 
the  latter.  Not  a  few  immigrant  families  who  have 
been  interviewed  give  exactly  this  testimony,  ex- 
pressed in  their  own  way  and  not  in  technical  terms. 

220 


ADEQUATE  MATERNITY  CAEE 

Facts  of  this  kind  are  not  a  criticism  of  the  medical 
profession  as  an  agent  of  maternity  care.  They  are 
a  substantiation  of  the  statements  of  Doctor  Williams 
and  other  leading  physicians  as  to  the  inadequate 
training  in  obstetrics  which  many  physicians  now  in 
practice  received  during  their  medical  school  days, 
and  the  inadequate  training  which  many  medical 
schools  even  now  provide. 

If,  through  various  means,  the  amount  of  obstet- 
rical practice  brought  upon  the  rank  and  file  of  prac- 
titioners were  increased,  it  would  tend  to  increase 
the  fee  rates  and  also  the  haste  on  the  physician's 
part  which  is  now  one  of  the  chief  evils  in  obstetrical 
practice.  So  large  an  amount  of  the  practice  of 
obstetrics  among  the  foreign  born  is  now  in  the 
hands  of  midwives  that  the  medical  profession  has 
everything  to  gain  by  seeing  that  suitable  substi- 
tutes for  the  midwife  are  provided  under  real  medical 
supervision.  The  impossibility  of  the  private  physi- 
cian acting  at  this  time  as  this  substitute  for  the 
masses  of  the  foreign  born  should  be  frankly 
recognized. 

An  adequate  substitute  for  part  of  the  midwife's 
service,  supervision,  and  nursing  care  before  and  after 
confinement,  is  provided  by  public  maternity  clinics. 

THE   PRENATAL    CLINIC 

Prenatal  clinics  are  now  established  in  many  cities 
under  the  auspices  of  private  organizations  or  de- 
partments of  health,  as  centers  to  which  pregnant 
women  may  come  for  examination  and  advice, 
whether  these  women  employ  their  own  physicians 

221 


IMMIGRANT  HEALTH  AND  COMMUNITY 

or  go  to  an  organized  teaching  system  for  maternity 
care.  The  advantages  of  obstetrical  diagnosis  and 
of  supervision  and  education  by  the  nurse  in  the 
woman's  home  during  pregnancy  and  the  post- 
partum period,  can  be  provided  irrespective  of  the 
care  at  confinement. 

One  of  the  great  limitations  upon  the  extension  of 
this  system  has  been  that  many  private  physicians 
have  been  unfamiliar  with  the  prenatal  clinic  or  with 
its  benefits.  Others  have  been  unwilling  to  make 
use  of  it  because  they  regarded  it  as  an  interference 
with  their  practice.  For  these  and  other  reasons  pre- 
natal clinics  have  made  little  headway  in  persuading 
the  private  practitioner  to  send  his  patients  to  them 
for  examination  and  for  nursing  service. 

In  several  cities  in  which  a  system  of  supervising 
the  midwife  has  been  well  worked  out,  the  prenatal 
clinics  play  an  important  part  in  this  connection. 
The  nurses  are  in  contact  with  the  midwives,  the 
midwives  bring  their  cases  to  the  clinic  for  consulta- 
tion, and  so  the  system  of  clinics  with  nursing  service 
not  only  assists  the  mother,  but  makes  the  super- 
vision of  the  midwives  more  efficient.  It  tends  to 
help  the  better  midwives  and  to  drive  out  the 
poorer. 

Since  midwives  are  so  predominant  a  factor  in 
maternity  care  among  the  foreign  born,  it  is  of  the 
first  importance  that  prenatal  clinics,  maternity  hos- 
pitals, and  other  facilities  for  good  maternity  care 
shall  make  a  special  effort  to  work  with  them.  Some 
maternity  hospitals  have  developed  social-service 
departments,  which  make  a  special  effort  to  do  this, 
but  they  seem  to  have  made  only  a  limited  contribu- 

222 


ADEQUATE  MATERNITY  CARE 

tion   to   the  technique  of  dealing  with  the  foreign 
born. 


MATERNITY  CENTER  ASSOCIATION  OF  NEW  YORK 

The  Maternity  Center  Association  of  New  York  has 
devoted  special  attention  to  immigrants  in  planning 
its  service,  and  its  experience  and  methods  may  be 
described  as  a  suggestion  for  other  organizations, 
private  and  public.  This  organization  dealt  with 
some  seventy-five  hundred  maternity  cases  during 
one  recent  year,  at  least  75  per  cent  of  the  mothers 
being  foreign  born.  The  association  divides  the  city 
into  zones.  There  is,  or  there  is  to  be,  a  maternity 
center  for  each  zone.  Each  zone  has  a  subcenter 
known  as  a  station.  Each  station  has  a  weekly 
clinic.  In  order  to  overcome  one  feeling  or  "preju- 
dice" of  many  foreign-born  mothers,  the  clinics  are 
conducted  by  women  physicians.  The  nurse  at  each 
station  holds  daily  office  hours,  where  mothers  from 
anywhere  in  that  district  may  come  for  consultation. 

The  nurse  carries  on  prenatal  work  in  the  homes, 
visiting  expectant  mothers  once  every  two  weeks  "if 
the  patient  is  normally  well,"  up  to  the  seventh 
month,  and  weekly  after  that.  During  the  entire 
time  the  nurse  keeps  careful  record  of  the  woman's 
condition  and  brings  her  into  the  clinic  if  there  is 
any  suspicion  of  trouble. 

The  maternity  nurse  of  the  center  does  no  bedside 
nursing,  but  arranges  with  another  organization  for 
this  kind  of  care.  The  nurse  visiting  the  home  of 
the  patient  is  supposed  to  make  an  analysis  of  the 

environment  in  which  her  patient  lives  and  to  correct 

223 


IMMIGRANT  HEALTH  AND  COMMUNITY 

any  environmental  defects,  since  the  mother's  men- 
tal condition  is  as  important  as  her  physical  condi- 
tion, or  is  a  part  of  it.  The  nurse  helps  to  make 
arrangements  for  care  at  delivery  and  to  secure 
hospital  care  if  it  is  desired. 

The  patient  is  supposed  to  send  word  to  the 
maternity  station  when  she  goes  into  the  hospital, 
or  to  notify  the  nurse  when  delivery  is  expected,  so 
that  she  can  arrange  for  nursing  care  at  home. 

The  Maternity  Center  Association  considers  ma- 
ternity and  prenatal  work  as  a  teaching  proposition, 
and  one  afternoon  a  week  the  nurse  has  a  demon- 
stration lesson  at  the  station  where  she  instructs 
mothers  (using  a  life-size  baby  doll)  in  the  care  of 
a  baby,  shows  the  proper  layette,  and  so  forth.  One 
week  the  nurse  gives  this  instruction  or  demonstra- 
tion to  the  mothers;  the  following  week  the  mothers 
show  the  nurse  the  proper  way  to  do  it.  The  nurse 
has  patterns  and  shows  them  how  to  make  the  baby's 
clothes,  how  to  make  maternity  clothes,  or  how  to 
alter  their  own  to  meet  the  emergency. 

The  doctors  and  nurses  appointed  to  the  work  are 
chosen  for  special  qualifications:  Public  health  and 
maternity  experience,  understanding  and  experience 
in  handling  foreign  groups,  in  many  cases  knowledge 
of  the  foreign  language — all  being  considered.  Igno- 
rance of  a  foreign  language,  however,  is  not  an  abso- 
lute bar  to  the  engagement  of  a  nurse,  as  interpreters 
can  always  be  found  and  thoroughly  competent, 
sympathetic,  and  experienced  nurses  cannot.  This 
association  is  the  only  one  of  all  those  with  whom  we 
have  been   in   touch   which    insists    that    its   local 

station,  doing  prenatal  or  similar  work,  must  have 

224 


ADEQUATE  MATERNITY  CARE 

either  a  paid  interpreter  or  a  doctor  and  nurse,  both 
of  whom  speak  the  language  or  languages  necessary. 

The  nurses  co-operate  with  the  midwives  in  their 
districts  and  report  to  them  as  to  the  condition  of 
their  cases,  just  as  they  do  to  physicians.  Midwives 
are  said  frequently  to  report  the  names  and  addresses 
of  women  who  have  engaged  them  for  their  coming 
confinement.  The  nurses  visit  the  midwife's  cases 
as  they  do  those  referred  by  a  physician. 

The  neighborhood  response  to  the  activities  of  the 
maternity  centers  thus  conducted,  seems  to  show 
that  the  plan  of  work  makes  itself  known  to  the 
foreign-born  mothers  of  the  district  and  calls  forth  a 
rapidly  increasing  utilization  of  the  service  offered. 
The  Maternity  Center  Association  of  New  York  is 
emphasizing  the  adaptation  of  its  prenatal  and 
maternity  service  to  immigrants  in  a  manner  which 
should  render  its  work  of  great  interest  to  depart- 
ments of  health  and  private  organizations  through- 
out the  country.  The  prenatal  clinics  supplement 
the  work  of  the  obstetrician,  but  since  they  do  not 
provide  for  the  actual  delivery  they  cannot  supplant 
the  midwife. 

MATERNITY    SERVICE   BY   MEDICAL    SCHOOLS 

The  only  important  substitute  for  the  midwife  which 
has  been  thus  far  developed  on  an  extensive  scale  is 
the  organized  maternity  service  connected  mth  the 
medical  school,  including  a  hospital  and  an  out- 
patient system  of  care.  This  system  is  extraordi- 
narily little  known  to  the  general  public.     Medical 

students  must  be  taught  obstetrics  in  some  fashion, 

225 


IMMIGRANT  HEALTH  AND  COMMUNITY 

and  the  best  medical  schools  throughout  the  country 
have  developed  a  maternity  service,  partly  for  this 
purpose  and  partly  to  benefit  the  mothers  of  the 
community  who  cannot  afford  to  pay  for  private 
obstetrical  care.  When  thoroughly  developed,  the 
system  includes  the  following  elements: 

1.  A  maternity  hospital,  which  may  have  paying 
and  part-paying  beds  as  well  as  free  beds. 

2.  One  or  more  "prenatal"  or  "antepartum"  or 
"pregnancy"  clinics,  as  they  are  variously  called. 
One  of  these  may  be  located  at  the  hospital  itself, 
and  others  in  various  parts  of  the  city.  At  each  of 
these  clinics  there  is,  at  regular  intervals,  a  physician 
well  trained  in  obstetrics,  with  the  necessary  equip- 
ment and  nursing  service  to  make  examinations  of 
pregnant  women. 

3.  A  visiting-nurse  service,  conducted  either  by  an 
outside  district  nursing  organization  or  by  the  in- 
stitution itself,  for  visiting  patients  in  their  homes 
during  pregnancy  (the  so-called  prenatal  work),  for 
attendance  after  delivery,  sometimes  for  giving  care 
at  confinement,  in  the  home. 

4.  The  medical  student  who,  under  certain  im- 
portant restrictions  and  under  supervision,  delivers 
patients  in  their  homes. 

The  operation  of  such  a  system  has  been  succinctly 
described  in  a  recent  article,  which  may  be  quoted:* 

The  patient  presents  herself  at  the  clinic.  She  is  ex- 
amined carefully  and  thoroughly.     She  is  visited  at  her 


1  Stephen  Rushmore,  M.D.,  and  Alonzo  K.  Paine,  M.D.,  "A 
Suggestion  for  the  Improvement  of  Obstetrics,"  Boston  Medical 
and  Surgical  Journal,  November  20,  1919,  pp.  615-618. 

226 


ADEQUATE  MATERNITY  CARE 


DEVELOPMENT  NEEDED  IN  MATERNITY  CAEE 


home  by  the  nurse,  who  sees  that  everj-thing  needed  at 
confinement  is  in  the  house.  She  visits  the  clinic  for 
further  examination  and  advice.  When  she  falls  into  labor 
word  is  sent  to  the  hospital  and  her  record  is  reviewed. 

227 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Attendants  from  the  hospital,  usually  two  undergraduate 
medical  students,  go  to  her  home,  sometimes  accompanied 
by  a  nurse.  Reports  are  sent  to  the  physician  at  the 
hospital,  on  printed  forms  covering  all  important  points 
to  be  noted  in  the  patient's  condition.  Preparations  are 
made  for  delivery,  and  if  labor  is  not  progressing  satisfac- 
torily the  patient  is  seen  at  once  by  the  resident  physician. 
If  necessary,  the  patient  is  transferred  to  the  hospital  or  a 
member  of  the  visiting  stafif  is  called  so  that  the  patient 
gets  adequate  care  throughout. 

The  resident  physician  at  the  hospital  knows  the  patient's 
condition  and  the  progress  of  the  labor  through  the  frequent 
reports  sent  to  him.  He  goes  to  her  when  he  is  needed 
and  when  he  leaves  she  is  in  the  hands  of  competent  ob- 
servers who  can  send  for  him  when  necessary.  Following 
the  confinement  at  the  house  there  are  visits  by  the  doctor, 
the  medical  students,  and  the  niu'se  until  the  patient  is 
discharged. 

There  are  several  essential  points  of  such  an  organ- 
ized system  of  maternity  care.  Obstetrical  diagnosis 
is  desirable  as  early  in  pregnancy  as  possible.  This 
means  determining  whether  the  woman  can  bear  a 
child  normally  or  whether  she  has  some  difficulty, 
such  as  a  malformation  of  the  pelvis,  which  would 
require  special  care  or  a  surgical  operation  in  the 
hospital. 

Supervision  and  instruction  during  pregnancy  is  a 
desirable  feature.  This  means  periodical  visits  of 
the  nurse  to  the  mother's  home  to  teach  her  to  care 
for  herself  and  to  prepare  for  the  coming  child. 
Medical  conditions  must  be  watched  during  preg- 
nancy, so  the  mother  comes  to  the  prenatal  clinics 
for  further  examination  by  the  obstetrician;  periodi- 
cal tests  of  urine,  and  so  forth,  are  regularly 
made. 

228 


ADEQUATE  MATERNITY  CARE 

Delivery  is  under  supervision.  The  medical  stu- 
dent is  allowed  to  deliver  a  case  only  under  certain 
conditions,  and  must  pass  the  responsibility  to  a 
graduate  physician  specially  skilled  in  obstetrics, 
whenever  specified  conditions  arise.  Furthermore, 
the  preliminary  diagnosis  and  supervision  of  the 
patient  have  eliminated  all  those  pathological  or  ab- 
normal cases  which  could  be  foreseen. 

Obstetrical  emergencies  are  met  either  by  deter- 
mining them  in  advance  and  arranging  for  the  de- 
livery of  the  woman  in  the  hospital,  or  when  the 
emergency  is  unforeseen,  by  calling  the  resident  or 
visiting  physician,  precisely  that  degree  of  skill  being 
applied  to  each  case  which  tjie  case  actually  requires. 
The  normal  delivery  of  the  woman  who  has  already 
borne  children  almost  takes  care  of  itself,  while  an  ob- 
stetrical emergency  may  require  the  highest  degree 
of  medical  judgment  and  skill  to  save  the  mother  and 
baby. 

Postpartum  care  is  given  through  nursing  service 
in  the  home,  and  medical  supervision  is  continued 
during  the  whole  puerperal  period.  One  of  the  most 
important  parts  of  the  system  is  the  education  of  the 
mother  of  the  family  in  both  care  during  pregnancy 
and  care  of  the  baby  after  it  is  born. 

The  results  of  these  systems  of  organized  maternity 
service  have  been  astonishingly  good.  In  the  out- 
patient service  of  the  Boston  Lying-in  Hospital, 
students  of  the  Harvard  Medical  School  have  year 
after  year  delivered  2,000  cases  or  so,  with  none  or 
very  few  deaths.  In  Chicago  the  Lying-in  Hospital, 
during  nineteen  years  of  operation,  has  cared  for 

24,764  confinements,  with  only  eight  maternal  deaths 
16  229 


IMMIGRANT  HEALTH  AND  COMMUNITY 

among  the  patients  who  were  exclusively  under  its 
care. 

The  contrast  between  these  almost  vanishing  ma- 
ternal death  rates  and  the  maternal  death  rate  of 
about  5  to  1,000  in  the  United  States  as  a  whole,  is 
due  at  bottom  to  the  system  of  supervision.  The 
care  of  the  woman  at  confinement  is  fortunately  a 
comparatively  simple  thing  in  the  large  majority  of 
cases,  but  in  a  minority  of  cases  the  problem  is  diffi- 
cult, often  extremely  difficult.  The  emergencies, 
when  they  occur,  are  grave,  urgently  threatening 
two  lives.  Some  of  these  difficulties  and  emergencies 
can  be  foreseen  and  provided  for  in  advance,  so  that 
they  will  not  occur  at  all.  A  certain  small  proportion 
cannot  be  foreseen,  and  when  these  arise  just  that 
degree  of  skill  and  equipment  which  can  cope  with 
them  successfully  must  be  promptly  on  hand. 
Neither  the  unregulated  midwife  nor  the  general 
practitioner  working  alone  in  the  patient's  home  can 
meet  these  requirements. 

These  systems  have  been  largely  taken  advantage 
of  by  the  foreign  born.  In  Boston  something  like 
3,000  cases  a  year  are  delivered  in  their  homes  or  in 
the  maternity  hospitals  through  the  teaching  and 
hospital  services  connected  with  the  Harvard  and 
the  Tufts  Medical  Schools.  A  large  proportion  of 
these  cases  are  Jewish  or  Italian.  The  clientele  of 
the  Chicago  Lying-In  Hospital  is  largely  Jewish  and 
includes  a  considerable  number  from  other  foreign- 
born  groups.  In  New  York  the  same  is  true.  The 
following  figures  from  the  study  by  Dr.  Lewinski- 
Corwin,  previously  mentioned,  make  an  interesting 

comparison  between  races: 

230 


ADEQUATE  MATERNITY  CARE 

TABLE  XXIX 

The  Kinds  of  Maternity  Care  Secured  by  Patients  of  Various 

Races  in  New  York,  1903-18 

(Testimony  secured  from  mothers  during  block  canvass) 


Race 

Total 

Number 
Cases 

Number      Delivered     bt 
Organized  Medical  Care 
IN  Hospital  or  in  Home 

Percent- 
age so 
Delivered 

Slavs 

311 

406 
213 
190 

8 
10 
64 

47 

2  6 

Italians 

Jews 

2.5 
30  0 

Native  born 

24.7 

The  cheapness  of  the  maternity  care  offered  by 
these  organized  systems  is  one  of  their  great  advan- 
tages. The  medical  students  do  the  work  for  nothing. 
So  do  the  visiting  obstetricians.  The  resident  phy- 
sicians, who  stand  between  the  students  and  the 
visiting  staff,  generally  receive  nominal  or  moderate 
salaries,  as  they  are  securing  valuable  special  expe- 
rience. The  only  expenses  to  be  met  are  for  over- 
head, upkeep  of  the  plants,  and  home-nursing  service. 
Many  of  the  patients  can  pay  enough  to  cover  a 
considerable  porportion  of  these  expenses,  and  some 
of  them  can  pay  enough  to  cover  all.  Consequently, 
the  service  can  be,  and  is,  offered  at  nominal  rates, 
and  the  home  deliveries  are  usually  provided  free 
when  necessary. 

The  only  obstacle  to  the  indefinite  extension  of  this 
almost  ideal  system  is  the  limited  number  of  medical 
students.  During  the  last  few  years  the  annual  num- 
ber of  medical  graduates  has  been  about  2,500  or 
2,600.  Even  if  each  of  these  students  were  to  deliver 
20  cases  in  their  homes — which  is  a  very  much  larger 
number  than  students  deliver  in  most  medical  schools 

— the  total  number  of  cases  delivered  by  all  the 

231 


IMMIGRANT  HEALTH  AND  COMMUNITY 

medical  students  in  the  United  States  would  be  only 
about  50,000.  This  is  about  2  per  cent  of  the  births 
in  the  United  States.  It  is  just  about  the  number  of 
births  which  occur  each  year  in  the  city  of  Chicago. 

The  number  of  medical  colleges  is  on  the  decrease 
rather  than  on  the  increase.  There  are  at  the  present 
time  95  medical  schools  in  the  country,  in  about  60 
different  communities.^  For  reasons  of  medical  teach- 
ing efficiency  they  tend  to  be  in  large  centers  of 
population.  There  were  in  the  United  States,  in  1917, 
272  communities  of  over  25,000  estimated  popula- 
tion.^ There  were,  according  to  the  census  of  1910, 
2,173  communities  of  between  2,500  and  25,000. 
The  rural  area  of  the  United  States  includes  a  little 
more  than  half  the  total  population.  The  medical 
colleges  and  the  medical  students  can  develop  a  sys- 
tem and  set  a  standard  of  medical  care,  but  they  can 
provide  for  only  a  minute  fraction  of  the  mothers  of 
the  United  States  in  their  time  of  need. 

A   PRACTICAL   PLAN 

The  only  effective  maternity  service  thus  far  devel- 
oped has  been  the  out-patient  teaching  service,  and 
the  number  that  can  be  reached  by  this  is  limited  by 
the  number  of  medical  schools.  A  practicable  method 
of  securing  the  advantages  of  thi^  system  without 
the  use  of  the  medical  student  has  been  suggested 
by  Dr.  A.  K.  Paine,  as  a  member  of  the  committee  on 


^  According  to  1918   classification   of   American    Medical    As- 
sociation. 

2  Department  of  Commerce,  Bureau  of  the  Census,  Bulletin  138, 
Table  VI. 

232 


ADEQUATE  MATERNITY  CARE 

Prenatal  Care  and  Obstetrics,  of  Boston.  We  may 
quote  from  the  statement  made  by  Doctors  Paine 
and  Rushmore:^ 

The  scheme  proposed  for  discussion  by  the  committee  is 
the  substitution  for  the  medical  student  of  graduate  and 
undergraduate  nurses,  preserving  in  other  respects  the 
system  now  in  use  in  many  hospitals. 

There  would  then  be  in  a  municipal  or  other  hospital 
an  obstetrical  department  as  a  center  to  which  all  cases 
needing  hospital  care  could  be  sent.  Prenatal  clinics  would 
be  established  here  and  at  substations  in  the  district  if 
necessary.  Patients  at  their  homes  would  be  cared  for  by 
physicians  from  the  hospitals,  who  would  be  assisted  by 
nurses  as  they  are  now  assisted  by  medical  students.  If 
transportation  were  provided  by  automobile,  th-e  number 
of  cases  seen  and  cared  for  would  be  greatly  increased  for  a 
given  amount  of  effort. 


THE   COST   OF  A    COMMUNITY  PLAN 

The  cost  of  this  plan  of  service  is  important,  since 
its  field  of  action  would  be  the  large  number  of  cases 
now  covered  by  the  midwife  and  the  smaller,  but 
important,  number  who  now  receive  no  care,  or  get 
medical  charity  at  the  hands  of  physicians  or  insti- 
tutions. In  their  committee  report,  Doctors  Paine 
and  Rushmore  made  estimates  which  are  worth 
quoting  in  detail. 

The  following  items  of  nurses,  physicians,  supplies, 
and  automobiles  must  be  included  in  the  cost  of  such 
a  system.  The  estimates  are  on  the  basis  of  5,000 
deliveries  cared  for  during  a  year : 

1  Stephen  Rushmore,  M.D.,  and  Alonzo  K.  Paine,  M.D.,  "A  Sug- 
gestion for  the  Improvement  of  Obstetrics,"  Boston  Medical  and 
Surgical  Journal,  November  30,  1919,  pp.  615-618. 

233 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Nurses. — Needed  for  antepartum  visits,  for  attendance  at 
confinement,  and  for  postpartum  visits. 

Antepartum  visits. — Each  patient  should  be  visited  once 
at  her  home  by  the  nurse  to  see  that  she  has  made  proper 
preparations  and  has  the  necessary  suppHes  on  hand. 
For  normal  cases  no  other  visit  is  necessary,  as  the  patient 
reports  at  the  clinic  for  observation  and  examination.  It 
is  estimated  that  the  patients  needing  special  care,  as  in 
toxemia,  bleeding,  and  so  on,  will  require  3  visits  each  on 
the  average,  and  will  constitute  about  5  per  cent  of  the 
total  number  of  patients.  Of  these  patients  needing 
special  care,  a  considerable  number  will  be  actual  in-patient 
cases,  and  will  have  to  be  transferred  to  the  hospital.  If 
4  visits  per  patient  were  necessary,  it  would  make  1,000 
extra  antepartum  visits,  making  a  total  of  6,000  antepartum 
visits. 

If  the  year  be  reckoned  as  comprising  300  nursing  days, 
this  gives  20  visits  per  day,  which  would  require  the  whole 
time  of  2  nurses. 

Five  thousand  births  in  the  course  of  a  year  gives  an 
average  for  one  day  of  13  plus,  which  may  be  regarded  as  14. 
Eight  hours  may  be  allowed  as  the  average  time  that 
would  have  to  be  spent  with  each  case.  With  an  eight- 
hour  day  this  would  be  14  nurses  for  a  day's  work.  If  2 
nurses  attended  each  case,  28  would  be  required.  Of  these 
one  half  would  be  graduate  nurses,  the  other  pupil  nurses. 

Postpartum  visits. — ^Averaging  a  visit  a  day  for  10  days, 
there  would  be  14  visits  for  the  first  daj^  increasing  each 
day  until  on  the  tenth  day  there  would  be  a  maximum  of 
140  visits,  the  daily  number  from  that  time  on.  Post- 
partum visits  would  require  an  hour  for  each  and  would 
therefore  require  18  nurses  a  day. 

It  is  estimated  that  5  supervisors  would  be  required  for 
this  total  of  48  nurses. 

Cost:  14  graduate  nurses  and  5  supervisors  at 

$100  per  month $  1,900 

34  pupil  nurses  (average  $42  per  month) . .        1,428 

Total  per  month $  3,328 

Total  per  year 39,936 

234 


ADEQUATE  MATERNITY  CARE 

Physicians. — There  would  be  a  consulting  or  visiting 
staff  and  a  resident  staff,  only  the  latter  involving  expense. 

Probably  6  men  would  be  necessary  for  the  resident 
staff.  They  would  be  on  24-hour  shifts.  Thus,  3  men 
would  be  taking  confinements  for  24  hours,  making  an 
average  of  about  5  a  day.  For  the  next  24  hours  these  3 
men  would  be  making  postpartum  visits,  on  the  third  and 
tenth  days  of  the  puerperium,  attending  to  the  antepartum 
clinics,  keeping  up  records,  and  would  have  one  undis- 
turbed night  for  sleep.  Each  man  would  have  one  evening 
and  afternoon  off  in  six. 


Cost:  6  at  $36  per  month  (average) $  216 

per  year 2,592 

It  might  be  well  if  these  men  were  salaried  and  the  term 
of  service  might  well  be  a  six  months'  service. 

Supplies. — The  cost  of  supplies  would  not  be  very  great, 
as  many  of  the  supplies  are  provided  by  the  patients, 
purchased  under  the  direction  of  the  nurse  or  doctor. 
A  dollar  per  patient  would  be  ample — $5,000. 

Ambulance — automobile. — In  order  that  a  physician  shall 
be  able  to  take  care  of  five  cases  a  day,  on  the  average, 
and  to  enable  nurses  to  attend  cases  promptly  at  any  time 
of  the  day  or  night  in  any  part  of  the  district,  automobile 
transportation  would  be  necessary.  It  is  estimated  that 
four  ambulances  or  other  automobiles  would  be  required. 

The  average  cost  per  month  of  one  ambulance  at  the 
Boston  City  Hospital  is  $365  (all  costs,  including  drivers 
on  8-hour  shifts). 


Cost:  4  autos  per  month $   1,460 

per  year 17,520 

Total  Cost:  Nurses $39,936 

Physicians 2,592 

Supplies 5,000 

Automobiles 17,520 

Total $65,048 

235 


IMMIGRANT  HEALTH  AND  COMMUNITY 

This  would  make  an  average  cost  per  case  (5,000 
cases)  of  $13.02.  It  may  be  that  the  allowance  for 
automobile  service  is  too  generous,  since  less  expen- 
sive machines  than  ambulances  could  be  employed, 
except  for  emergency  cases  requiring  transfer  to  a 
hospital.  These  are  relatively  few.  We  might  safely 
reduce  the  automobile  expense  to  $12,500.  On  the 
other  hand,  the  physicians'  and  nurses'  salaries  seem 
unduly  low.  In  many  communities  the  visiting 
staff  should  have  fees,  and  the  resident  staff  should 
have  salaries  of  $75  to  $100  per  month.  Ten  thou- 
sand dollars  should  be  allowed  for  medical  salaries. 
The  cost  of  hospital  care  for  250  cases  (5  per  cent  of 
5,000),  at  an  average  of  $50  each,  would  be  $12,500. 
Finally,  overhead  supervision  and  incidental  ex- 
penses would  have  to  be  allowed  for.  This  would 
be  less  if  the  maternity  care  system  were  part  of  a 
larger  organization.  Four  thousand  dollars  to  $7,500 
should  be  sufficient.  The  total  of  all  would  be  be- 
tween $90,000  and  $100,000,  or  between  $18  and  $20 
per  case.  This  figure  is  presented  more  for  purposes 
of  discussion  than  as  a  substantiated  estimate. 

A  considerable  proportion  of  the  recipients  of  this 
care  could  pay  this  amount,  since  they  pay  as  much 
as  this  now  to  midwives.  It  should  be  considered  not 
a  charity,  but  a  public  service. 

It  would  be  essential  for  the  successful  operation 

of  this  plan  that  a  sufficient  number  of  the  right  type 

of  women  be  secured  as  nurses  and  that  the  proper 

training  be  given.     The  term  "midwife"  must  be 

abandoned  for  the  term  "nurse,"  with  the  prefix 

"maternity"  or  "obstetrical."     "Maternity  nurse" 

would  seem  to  be  the  best  title.    After  all,  the  great- 

236 


ADEQUATE  MATERNITY  CARE 

est  drawback  to  midwifery  in  this  country  is  that 
which  nursing  faced  in  its  *'  Sairy  Gamp "  stage. 
Nursing,  before  the  time  of  Florence  Nightingale,  had 
many  Sairy  Gamps.  Miss  Nightingale's  greatest 
service  was  so  to  dignify  the  profession,  so  to  touch 
the  imagination  of  the  community — and  especially 


NURSE  MUST  RELIEVE   THE    DOCTOR    IN    CARING    FOR    MANY 

BABIES    BORN 


of  womankind — that  nursing  became  a  vocation 
which  could  draw  the  finest  types  of  womanhood. 
The  care  of  the  mothers  of  our  nation  at  the  time 
when  they  are  bringing  babies  into  the  world  is  a 

worthy  and  inspiring  service,  and  must  be  dignified 

237 


IMMIGRANT  HEALTH  AND  COMMUNITY 

as  such.  Then  women  of  the  fine  type  who  have 
entered  the  ranks  of  nursing  during  recent  years  will 
enter  this  branch  of  the  same  profession. 

Specialization  within  the  nursing  field  becomes 
constantly  more  common  and  more  important.  The 
various  branches  of  visiting  and  public  health  nurs- 
ing, hospital  or  institutional  nursing,  teaching,  and 
administration — all  are  recognized  as  distinct  types 
of  work  which  demand  special  training.  The  cur- 
riculum of  the  training  school  must  be  amplified, 
made  more  flexible,  and  relieved  of  routine  elements 
unnecessary  to  the  best  nursing  as  such.  The  latter 
part  of  the  nurse's  course  must  give  opportunity  for 
specialization. 

Maternity  care  should  be  regarded  as  one  of  the 
definite  branches  of  nursing,  for  which  a  certain  num- 
ber of  those  entering  the  profession  should  be  trained 
during  their  undergraduate  course.  Postgraduate 
courses  in  this  subject  should  be  provided  for  women 
already  engaged  in  nursing.  The  field  of  the  mater- 
nity nurses  will  be  so  largely  among  the  foreign  born 
that  their  training  should  include  instruction  in  the 
backgrounds  of  various  races  of  immigrants  and  in 
the  special  technique  of  dealing  with  them  in  mater- 
nity work. 

DISTRICTING  THE   SERVICE 

Some  points  made  by  Miss  Frances  Perkins,  of  the 

Maternity  Center  Association  of  New  York,  in  her 

study  of  a  desirable  standard  of  maternity  service, 

should  be  incorporated  in  the  proposed  plan  for 

organizing  maternity  care.     She  suggests  that  the 

238 


ADEQUATE  IVIATERNITY  CARE 

stations  for  prenatal  and  other  service  to  mothers 
and  babies  should  be  regarded  as  neighborhood  cen- 
ters, and  that  each  "should  not  be  a  formidable, 
official-looking  place,  but  should  rather  be  small, 
simple,  and  accessible."  In  a  large  community  each 
such  center  should  be  organized  to  care  for  about 
400  cases  per  year.  This  would  mean  one  center  for 
approximately  each  12,000  or  15,000  population. 
This  corresponds  to  the  general  standard  for  deter- 
mining the  size  of  a  district  for  general  health-center 
purposes  discussed  later. 

This  local  center  will  be  primarily  the  center  for 
the  nursing  service,  although  the  prenatal  clinic  will 
be  held  there  by  the  obstetrical  staff  at  the  necessary 
intervals.  The  resident  physicians  and  obstetricians 
who  provide  the  medical  service  and  supervision  must 
be  grouped  into  larger  units,  since  it  would  not  be 
economical  to  have  each  center  for  400  cases  a  year 
maintain  its  independent  staff. 

Maternity  work  is  of  an  emergency  nature.  The 
approximate  date  of  each  confinement  can  be  deter- 
mined in  advance,  but  not  the  exact  day  or  hour.  It 
is  highly  important,  therefore,  to  regularize  the  calls 
of  both  nurses  and  physicians  as  much  as  possible. 
Regularizing  can  be  managed  best  when  a  consider- 
able number  of  districts  are  so  located  as  to  make  it 
possible  to  utilize  slack  time  in  one,  when  there  hap- 
pen to  be  few  calls,  to  fill  up  the  needs  in  another, 
where  there  happen  to  be  many.  If  too  small  an 
area  is  taken,  there  will  be  periods  with  but  few  calls, 
but  a  large  enough  staff  must  be  maintained  to  carry 
the  peak  of  the  load.    This  defect  can  be  overcome 

by  having  many  local  areas  for  the  nursing  and 

239 


IMMIGRANT  HEALTH  AND  COMMUNITY 

neighborhood  service  during  the  prenatal  and  post- 
partum periods  grouped  into  larger  units. 


VISITING   HOUSEKEEPERS   ESSENTIAL 

Visiting  houseworkers  should  be  an  element  in  the 
plan,  developed  as  fully  as  financial  considerations 
permit.  One  of  the  real  reasons  for  the  midwife  is 
the  help  that  she  gives  in  the  home,  and  the  decrease 
in  this  part  of  the  midwife's  work  is  a  misfortune  to 
many  families.  The  mother  cannot  stay  long  enough 
in  bed  after  confinement  when  there  is  no  one  to 
care  for  her  family  and  children. 

Houseworkers  maintained  on  salary  could  be  attached 
to  each  center.  They  should  do  their  work  [says  Miss 
Perkins]  under  the  charge  of  the  nurse  in  charge  of  the  case. 
They  should  prepare  the  patient's  food,  attend  to  her  minor 
wants,  as  directed  by  the  nurse.  In  addition,  they  should 
go  out  with  the  nurse  and  the  doctor  at  the  time  of  de- 
livery, and  at  once  assume  responsibilities  for  the  care  of 
the  home,  including  the  chUdren.  The  number  of  hours 
per  day  spent  in  household  work  for  each  patient  will 
vary  according  to  the  circumstances  and  the  need  of  the 
particular  family.  These  houseworkers  should  be  given 
certain  definite  training  and  instruction  before  they  are 
sent  out. 

Miss  Perkins  estimates  that  about  one  houseworker 
should  be  provided  for  every  one  hundred  cases  deliv- 
ered, but  this  will  vary  much  with  the  character  of 
the  district.  The  extra  cost  of  these  houseworkers 
may  be  an  obstacle.  The  amount  will  have  to  be 
worked  out.  Probably  much  of  this  service  can  be 
paid  for  by  some  families. 

240 


ADEQUATE  MATERNITY  CARE 

INTERPRETING 

According  to  the  practical  experience  of  the  Mater- 
nity Center  Association,  it  will  be  highly  necessary 
to  have  some  one  in  each  center  able  to  speak  each 
language  prevalent  in  the  district.  Where  nurses  or 
physicians  of  the  center  speak  the  languages  suffi- 
ciently well,  paid  interpreters  need  not  be  engaged. 
In  some  centers  it  will  be  necessary  to  engage  them 
or  to  have  a  certain  number  of  residents  of  the  dis- 
trict on  call  for  such  service,  to  be  paid  when  called. 
Usually  the  need  can  be  met  by  selecting  some  one 
to  do  clerical  or  other  work  at  the  center  who  can 
speak  some  of  the  needed  languages,  supplementing 
what  the  nurses  or  physicians  know. 

ADVANTAGES   OF   THE   PLAN 

The  four  advantages  to  their  plan  are  stated  by  Doc- 
tors Rushmore  and  Paine, ^  as  follows: 

1.  It  may  be  employed  in  communities  in  which  no 
medical  school  exists.  These  are  often  the  communities 
in  which  the  need  for  adequate  care  is  the  greatest. 

2.  It  will  greatly  increase  the  number  of  women  who 
get  adequate  prenatal  and  obstetrical  care. 

3.  It  will  tend  to  improve  the  standards  of  obstetrical 
practice.  Hospitals  with  obstetrical  departments  wiU 
become  much  more  numerous.  Physicians  who  are  to  be 
in  charge  of  these  departments  will  be  selected  because  of 
their  greater  proficiency  and  by  additional  experience  will 
make  further  progress.  House  officers  will  have  more 
experience  and  better  training  and  thus  be  better  fitted  when 
they  enter  independent  practice. 

4.  It  will  greatly  increase  the  supply  of  obstetrical  nurses. 

1  Stephen  Rushmore,  M.D.,  and  Alonzo  K.  Paine,  M.D.,  "A 
Suggestion  for  Improvement  of  Obstetrics,"  Boston  Medical  and 
Surgical  Journal,  November  30,  1919,  pp.  615-618. 

241 


IMMIGRANT  HEALTH  AND  COMMUNITY 

This  plan  would  seem  to  be  adaptable  to  a  com- 
munity of  any  size  where  a  maternity  hospital  exists 
or  where  maternity  beds  can  be  made  part  of  the 
existing  general  hospital.  It  can  be  applied  to  small 
communities,  because  the  overhead  costs  of  provid- 
ing the  expert  care,  such  as  the  obstetrical  and  nurs- 
ing supervisors,  can  be  distributed  over  a  large  area. 
With  the  development  of  the  automobile  there  would 
seem  to  be  no  essential  difficulty  in  extending  it  even 
to  rural  areas.  The  well-trained  physician  in  private 
practice  has  nothing  to  lose  by  such  a  system.  In 
fact  he  would  be  the  gainer  by  it,  because  if  he  wished 
he  could  utilize  the  prenatal  nursing  service  and 
secure  the  consultation  of  the  obstetricians  of  the 
clinics  for  his  patients  without  losing  his  relation  with 
his  private  case. 

Another  very  important  advantage  of  the  plan  in 
communities  having  many  foreign  born  and  many 
midwives  would  be  that  the  plan  would  provide  an 
acceptable  substitute  for  the  midwife,  at  a  cost  about 
equivalent  to  the  usual  rates  for  the  midwife's  serv- 
ices; and  that  by  equipping  the  "maternity  nurses** 
with  proper  training  in  dealing  with  the  foreign  born, 
very  great  steps  could  be  taken  in  bringing  immigrant 
mothers  to  utilize  such  a  service. 

Furthermore,  an  advantage  not  discussed  by  Doc- 
tors Paine  and  Rushmore  will  be  very  apparent  in 
those  communities  where  there  are  many  midwives 
and  wherein  there  is  a  system  of  licensing,  regulating, 
and  supervising  the  midwives  in  their  practice.  This 
supervision  could  and  should  be  conducted  through 
the  local  and  central  stations  of  the  organized  mater- 
nity service,  to  which  the  midwives  would  report. 

242 


ADEQUATE  MATERNITY  CARE 

The  nurses  at  the  station  would  not  themselves  be 
inspecting  officials  of  the  Department  of  Health, 
which  would  have  the  legal  authority  over  the  mid- 
wives,  but  the  actual  contacts  between  nurses  and 
midwives,  as  it  works  out  now  in  New  York  or 
Newark,  would  assist  the  practice  of  the  better  mid- 
wives  and  make  the  practice  of  the  dirty  and  un- 
trained ones  much  more  difficult.  The  officials  ad- 
ministering the  law  of  regulation  and  supervision 
would  be  greatly  assisted  by  the  knowledge  gained 
through  these  contacts. 

THE    CO-OPERATION    OF   THE   LAYMAN 

A  program  of  maternity  care  for  the  immigrant  can 
be  only  an  academic  proposal  unless  we  have  always 
in  mind  its  far-reaching  human  significance.  If  we 
regard  the  immigrant  not  as  a  transient  dweller  in 
our  midst,  but  as  a  part  of  this  country,  for  good  or 
ill;  if  we  see  that  Americanization  means  learning  to 
live  together,  the  approximation  of  different  racial 
or  group  standards,  the  understanding  by  each  of 
the  best  in  the  other,  a  unifying  of  communal  life 
into  a  richer  whole  than  before — then  this  plan  for 
maternity  care  can  be  a  powerful  instrument  in  our 
hands.  At  the  very  beginning  of  life  is  a  strategic 
time  to  approach  the  immigrant,  for  then  a  little 
understanding  and  sympathy  from  the  American 
health  worker  can  arouse  the  maximum  return  of 
understanding  and  sympathy  in  the  immigrant 
family. 

It  is  well  at  this  point  to  observe  how  little  the 
general  American  public  realizes  that  maternity  care 

243 


IMMIGRANT  HEALTH  AND  COMMUNITY 

is  a  problem;  that  in  America,  even  among  the 
native  born,  the  death  rate  of  women  in  childbirth 
or  from  causes  directly  due  to  childbirth  is  shock- 
ingly large  compared  to  that  of  most  other  civilized 
countries.  Cognately  the  general  public  knows  little 
about  the  midwife  or  any  facility  for  maternity  care 
other  than  the  private  physician. 

The  native  American  has  not  used  midwives  for  a 
long  time.  He  has  heard  about  them  in  a  vague 
way,  as  a  rather  shady  resource  of  immigrants.  He 
would  be  astonished  to  learn  that  midwives  deliver 
more  than  a  million  women  in  the  United  States  in 
a  year.  If  he  lives  in  a  large  city  which  has  a  medical 
school,  he  would  be  equally  surprised  to  learn  that 
several  hundred,  or  maybe  several  thousand,  women 
are  delivered  annually  by  medical  students. 

The  people  who  do  use  the  midwife,  the  people 
who  do  call  in  the  obstetrical  teaching  service,  are 
the  immigrants  and  the  poor;  but  these  have  not 
made  known  their  experience  because  they  rarely 
have  access  to  the  channels  of  public  expression. 
The  specialists  have  conducted  a  discussion,  chiefly 
within  their  own  circles.  The  Federal  Children's 
Bureau  has  recently  been  showing  in  its  publications 
the  high  rate  of  maternal  mortality  in  the  United 
States  and  the  grave  deficiencies  in  service  to  mothers 
at  confinement,  discovered  in  its  surveys  of  rural 
communities  and  of  towns.  These  facts  are  just 
beginnj^ng  to  filter  into  lay  journals  and  to  receive 
the  attention  of  public  meetings,  women's  clubs,  and 
other  groups  wherein  plain  people  come  together. 

It  is  well  that  this  is  beginning  to  be  so,  for  what- 
ever policy  medical  men,  health  workers,  nurses,  stu- 

244) 


ADEQUATE  MATERNITY  CARE 

dents,  and  surveyors  may  decide  upon.  In  so  large  a 
matter  as  maternity  care  for  the  women  of  this  coun- 
try a  program  can  be  effective  only  if  there  is  a 
general  appreciation  of  the  facts  on  the  part  of  the 
public,  a  keen  sense  of  the  needs  that  must  be  met, 
and  an  aroused  discontent  with  conditions  that  must 
be  bettered. 
17 


XII 

IMMIGRANT   DIETS   AND   AMERICAN   FOOD 

"Something  to  eat"  is  likely  to  be  the  immigrant's 
first  thought  after  landing,  and  this  fact  places  food 
in  the  first  rank  of  importance  in  our  plans  for 
Americanization.  Most  of  our  friends  from  other 
coimtries  come  to  America  in  the  very  cheapest  way 
and  are  unaccustomed  to  travel.  They  leave  home 
with  many  of  their  cooking  utensils  in  a  cloth  bag 
and  continue  their  housekeeping  on  shipboard,  in  the 
steerage,  feeding  their  children  and  themselves  from 
stores  brought  from  home.  Their  first  impression 
of  America  is  often  got  in  a  poorly  housed  restaurant, 
whose  proprietor  is  of  their  nationality.  From  him 
they  learn  where  to  get  some  of  their  native  foods, 
both  raw  and  cooked. 

Usually  they  establish  their  homes  in  neighbor- 
hoods or  colonies  of  their  own  countrypeople.  Here 
they  find  unfamiliar  housing  conditions.  They  are 
confronted  by  many  new  and  strange  appliances, 
such  as  agate  and  tin  cooking  utensils  instead  of 
copper  and  iron.  There  are  "  so  many  kinds  to  learn 
how  to  use,"  such  as  double  boilers,  "funny  egg 
beaters  that  you  turn  as  you  do  a  hand  organ,"  bread 
pans,  and  egg  poachers.  Then,  too,  there  are  "stoves 
with  no  fires  in  them  and  no  place  for  the  wood,  just 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

holes  in  irons,  and  if  you  turn  a  handle  and  apply  a 
lighted  match  fire  comes." 

In  the  colony  there  is  no  opportunity  to  learn 
about  American  foods,  either  raw  or  prepared,  nor 
what  American  dishes  approximate  the  food  values 
of  their  various  native  dishes.  Neither  do  they  know 
the  kind  and  amount  of  food  needed  in  a  day's  diet- 
ary under  the  new  living  conditions.  If  they  have 
come  from  countries  in  which  the  climate  is  very 
different  from  this,  or  if  their  occupation  here  is  more 
strenuous  than  at  home,  or  less  so,  they  do  not 
change  their  menu  accordingly.  They  have  always 
eaten  certain  kinds  of  food  prepared  in  certain  ways. 
Why  change? 

Certain  changes,  however,  are  forced  upon  them 
by  the  American  market.  Some  of  their  old  staples 
are  beyond  their  financial  reach  altogether  or  cost 
more  than  they  seem  to  the  immigrants  to  be  worth. 
As  a  result  they  limit  themselves  to  the  few  familiar 
foods  easily  obtainable,  thereby  eliminating  various 
essential  elements  and  completely  upsetting  the  bal- 
ance of  the  traditional  diet,  which  is  not  restored  by 
the  gradual  addition  of  American  products  chosen 
without  regard  for  food  values.  There  is  no  one  to 
tell  them  which  of  their  foods  to  keep  and  which  of 
this  country's  to  adopt,  nor  how  to  prepare  them. 

There  is  much  that  we  may  learn  from  these  people 
and  equally  much  for  them  to  learn  from  us  with 
profit.  If  we  study  their  ways  and  customs  and 
acquaint  ourselves  with  their  foods,  we  shall  be  able 
to  help  them  to  adjust  themselves  to  new  conditions 
with  as  few  changes  as  possible. 

During  the  influenza  epidemic   of   1918   it  was 

247 


IMMIGRANT  HEALTH  AND  COMMUNITY 

plainly  demonstrated  that  neither  district  nurses, 
settlement  workers,  nor  visiting  dietitians  knew  much 
about  the  foods  of  the  foreign-born  patients.  Gallons 
of  American  soups  and  broths  were  served  to  these 
people,  only  to  be  thrown  out  untouched.  This  was 
at  a  time  when  diet  was  an  important  element  in 
fighting  the  disease.  In  our  hospitals  and  dispen- 
saries we  usually  find  only  American  foods  prescribed 
for  diets.  Often  it  has  been  said,  "They  should  learn 
to  eat  American  foods  if  they  are  to  live  here.'*  We 
may  not  all  agree  with  this,  but  at  least  we  will 
agree  that  when  a  person  is  ill  and  needs  a  special 
diet,  it  is  no  time  to  teach  him  to  eat  new  foods.  It 
is  like  hitting  a  fellow  when  he  is  down.  Our  milk 
soups  are  nutritious,  but  so  are  theirs;  why  not  learn 
what  they  are  and  prescribe  them.?^  The  same  is 
true  of  other  foods. 

It  is  much  easier  for  the  dietitian  to  learn  the  foods 
of  the  foreign  born  than  for  these  people  to  adjust 
their  finances  to  a  new  dietary.  Often  their  income 
is  insufficient  to  buy  the  foods  which  they  know  they 
like.  Can  we  wonder  that  they  hesitate  to  invest  in 
food  about  which  they  are  uncertain .f^ 

A  Bohemian  family  of  father,  mother,  and  six 
children,  who  were  patients  at  a  dispensary,  were 
living  (or  staying)  here  on  an  income  of  twelve  to 
sixteen  dollars  a  week.  It  was  necessary  to  get  milk 
and  cereals  into  the  diet  of  the  children,  but  who, 
without  a  knowledge  of  Bohemian  foods,  dare  dis- 
turb that  very  limited  amount  which  could  be  spent 
for  food? 

Mrs.  Angelo's  husband  is  a  printer,  who  earns 
seventeen  dollars  a  week.    They  have  seven  children, 

248 


BIMIGRANT  DIETS  AND  AMERICAN  FOOD 

the  oldest  a  boy  of  eleven.  Barbara,  five  years  old, 
was  very  bowlegged  and  had  to  have  her  legs  broken 
to  straighten  them.  Three  younger  children  were 
sent  to  a  dispensary  food  clinic  for  diet  to  prevent 
their  being  bowlegged.  It  was  necessary  to  have  not 
less  than  two  and  one  half  quarts  of  milk  added  to 
their  food  each  day.  The  income  was  too  small  to 
allow  this,  so  the  man  got  night  work  to  pay  for  the 
milk.  This  shows  that  they  were  willing  to  go  at 
least  halfway  in  changing  diet  habits. 

The  derangement  of  the  hereditary  diet  often 
presses  hard  on  the  children.  Although  the  immigrant 
mother  is  accustomed  to  breast  feeding  her  babies, 
often  nourishing  them  thus  long  after  the  usual 
period,  early  in  life  the  child  is  given  other  food,  too 
often  from  the  family  table.  The  beneficial  effects 
of  breast  feeding,  therefore,  in  reducing  infant  mor- 
tality, are  often  counteracted  after  the  first  few 
months  of  life  by  unwise  additions  to  the  child's  diet. 
The  unwisdom  of  these  is  often  explained  by  the  im- 
migrant's dietary  backgrounds.  Much  instruction  for 
American  health  workers  lies  in  this  true  story,  told 
by  the  nurse  in  a  certain  clinic.  A  sick  baby  had 
been  brought  in  for  treatment.  Bad  diet  was  evi- 
dently the  trouble. 

"What  do  you  give  the  baby.'''*  asked  the  nurse  through 
an  interpreter. 

""What  we  have  ourselves,"  was  the  reply. 

"But  why  should  you  do  that  to  a  little  baby.''"  chided 
the  nurse. 

"I  always  did  that  in  our  own  country  with  my  other 
children  before  we  came  here." 

"But  what  did  you  give  your  children  lq  the  old  country 
that  you  had  yourselves.?" 

•  249 


IMMIGRANT  HEALTH  AND  COMMUNITY 


IN   EUROPE   THE   MILK   SUPPLY   WAS   IN   THE   FRONT   YARD 


"Soup  and  buttermilk,"  answered  the  mother,  smiling, 
apparently  at  the  pleasant  recollection  of  those  days. 

"What  do  you  give  your  child  now  that  you  have  your- 
selves?" 

"Beer  and  coflFee." 

250 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 


IN   AAIERICA  MILK   FROM   A  DISTANCE   MAKES   NEW 
REQUIREMENTS 

The  changed  relation  of  the  immigrant  family  to 
the  milk  supply  is  of  great  importance  for  the  mater- 
nity and  child-welfare  worker.     A  nurse  finds,  for 

instance,  an  Italian  mother  giving  her  child  no  milk; 

251 


IMMIGRANT  HEALTH  AND  COMMUNITY 

or  a  baby  sick  from  impure  milk;  or  again,  young- 
sters of  five  or  seven  years  of  age  getting  along  with 
no  milk,  or  only  a  tiny  bit  of  it  in  their  diet. 

In  her  native  land  this  Italian  woman  probably 
went  out  of  doors,  chased  the  goat,  milked  it,  and 
gave  her  child  to  drink.  The  milk  was  compara- 
tively clean  and  too  fresh  to  be  contaminated  by 
the  growth  of  bacteria.  Then  this  woman  comes  to 
America;  she  has  to  buy  milk,  and  it  seems  to  cost 
a  great  deal.  It  has  been  a  drink  to  her,  and  its  food 
value  is  not  appreciated.  It  seems  astonishing  to 
have  to  pay  out  a  large  sum  of  money  for  merely 
something  to  drink,  something,  furthermore,  which 
the  adults  of  the  family — particularly  the  man — are 
likely  to  care  very  little  about.  In  other  countries, 
like  Russia  and  Poland,  they  "live  on  the  cow." 
Milk  usually  costs  nothing  in  cash,  only  labor. 

From  immigrants  with  these  backgrounds  it  is  un- 
reasonable to  expect  a  sufficient  and  wise  use  of  milk, 
which  must  be  purchased  and  cared  for  under  city, 
or  even  town  conditions,  in  the  United  States,  unless 
there  is  built  up  a  wholly  new  attitude  of  mind  and 
of  family  habits  in  regard  to  it. 

There  are  certain  diseases  prevalent  among  the 
foreign  born  which  are  connected  with  their  change 
of  diet.  If  this  is  corrected  it  may  overcome  the  dis- 
ease. In  adapting  diets,  the  conditions  and  dietary 
habits  of  the  people  in  their  own  country,  as  well  as 
their  food  problems  here,  must  be  considered.  We 
shall  make  special  reference  to  some  diseases  in  which 
diet  is  a  factor  and  which  are  most  frequently  noted 
by  physicians,  nurses,  and  social  workers.  Fortu- 
nately it  is  possible  to  make  foreign  recipes  from  our 

252 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

American  raw  materials,  and  many  of  them  resemble 
our  dishes  so  closely  that  only  slight  changes  in  our 
recipes  are  necessary  to  produce  a  welcome  diet  for 
these  people. 

A  study  of  this  kind  should  be  extended  to  more 
race  groups  than  the  four  which  we  have  taken  up 
as  examples.  It  would  be  useful  to  enter  into  more 
details  in  many  respects,  for  success  in  dietary  work 
is  largely  a  matter  of  applying  certain  general  prin- 
ciples to  special  problems.  However,  a  study  of  the 
diets  of  the  Italians,  Jews,  Poles,  and  certain  Near 
East  races  may  serve  as  an  example  of  what  can  be 
done  in  adapting  immigrant  tastes  to  American  foods. 
Recipes  for  each  nationality  are  to  be  found  in  the 
Appendix. 

REPLACING    ITALIAN   FOOD 

The  Italians  who  come  to  America  are  the  peasants 
or  country  land  workers.  They  are  heavily  taxed  at 
home;  ready  money  is  scarce,  and  saving  is  a  slow 
process.  The  needs  of  the  family  are  supplied  directly 
or  by  exchange  with  neighboring  farmers.  Italy  has 
a  climate  much  like  that  of  California,  which  gives 
the  people  a  long  farming  season.  But  in  the  hottest 
part  of  the  summer  in  southern  Italy  very  little  work 
is  done  during  the  middle  of  the  day. 

Wheat,  corn,  and  other  cereals,  vegetables,  fruit, 
chickens,  pigs,  and  goats'  milk,  constitute  the  food 
products  of  the  farms.  A  greater  variety  is  found 
on  some  farms  than  on  others,  depending  on  the 
ambition  and  energy  of  the  farmer.  The  Italians 
make  their  own  cheese  from  goats'  milk;   they  lay 

in  a  store  of  dried  peppers  and  strings  of  garlic  for 

253 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  winter,  and  they  make  enough  tomato  paste  to 
last  during  the  season.  Here  and  there  one  finds 
olives  raised  for  family  use.  These  are  pickled,  both 
ripe  and  green,  and  used  not  only  as  a  relish,  but 
cooked  with  macaroni  or,  in  northern  Italy,  with  corn 
meal. 

The  country  people  of  northern  and  central  Italy 
have  a  well-balanced  diet,  with  protein  from  milk, 
cheese,  eggs,  and  meat;  carbohj^drates  from  bread, 
and  various  forms  of  macaroni;  mineral  matter  from 
fruits  and  vegetables;  fat  from  olive  oil;  and  vita- 
mines  from  milk,  vegetables,  and  egg  yolks.  South- 
ern Italians  obtain  a  more  varied  diet  than  the  other 
two  groups,  by  the  addition  of  innumerable  kinds  of 
fish.  The  Italians  in  the  cities  use  more  pastry  and 
cake  than  the  country  people,  and  have  altogether  a 
more  expensive  and  varied  diet. 

In  the  United  States  the  Italians  find  plenty  of  the 
foodstujffs  to  which  they  are  accustomed,  but  every- 
thing is  very  expensive,  notwithstanding  the  higher 
wage  scale.  More  meat  can  be  had  than  in  Italy,  and 
they  enjoy  that.  The  high  price  of  eggs  is  almost 
completely  prohibitive.  They  like  vegetables,  but 
to  use  enough  of  them  to  get  the  amount  of  satisfac- 
tion and  bulk  to  which  they  are  accustomed,  costs 
too  much.  Milk  is  considered  a  drink,  and  is 
purchased  only  after  the  solid  food  is  bought. 

These  conditions  result  in  one  of  two  compromises: 

either  they  leave  out  both  milk  and  meat  and  live 

largely  on  starches — bread,  macaroni,  and  potatoes 

— and  vegetables;  or  meat  is  used  at  the  sacrifice  of 

both  vegetables  and  milk.    The  health  of  the  family 

naturally  suffers  through  this  change  of  diet. 

254 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

Tlie  Italian  woman,  when  she  cooks  a  meal,  spends 
much  time  and  care,  and  the  results  are  very  appe- 
tizing. This  fact  shows  what  an  apt  pupil  she  would 
be  if  taught  early  on  her  arrival  how  to  market, 
what  familiar  foodstuffs  can  be  secured,  what  sub- 
stitutes can  be  used,  and  what  a  day's  dietary,  break- 
fast, dinner,  and  supper,  should  contain,  and  why. 

In  furnishing  this  instruction,  native  dishes  and 
raw-food  materials  should  be  included  wherever  pos- 
sible. If  olive  oil  is  a  luxury,  other  vegetable  oils,  of 
which  we  have  several,  may  be  introduced.  Soups 
may  be  given  the  Italian  flavor  of  tomato  or  garlic 
or  both.  To  them  may  be  added  macaroni  in  one  of 
its  various  forms,  or  rice,  and  this  will  furnish  thick- 
ening in  place  of  eggs.  Milk  soups  will  be  acceptable 
only  when  highly  flavored  or  after  the  family  have 
learned  to  like  white  sauces.  Vegetables  the  Italians 
have  always  liked,  and  w^hen  their  value  is  explained 
they  are  often  willing  to  substitute  them  for  meat. 

The  Italian  children  are  put  on  the  adults*  diet 
as  soon  as  they  are  out  of  swaddling  clothes.  The 
larger  the  abdomen  the  stronger  and  healthier  the 
mother  considers  the  child.  A  diet  of  milk,  strained 
cereal,  and  fruit  juices  is  unknown  to  an  Italian 
mother.  The  children  learn  to  take  tea  or  black 
coffee  and  bread  without  butter,  for  breakfast. 
Usually  this  means  a  meal  of  200  to  250  calories,  com- 
posed of  carbohydrates,  instead  of  one  of  500  calories, 
combining  protein,  carbohydrates,  mineral  matter, 
and  fats.  At  noon  the  meal  often  consists  again,  as 
with  the  adults,  of  bread  with  a  piece  of  bologna  and 
more  tea  or  coffee.     At  supper  time  comes  the  big 

meal  of  the  day.    Too  large  an  amount  of  macaroni 

255 


IMMIGRANT  HEALTH  AND  COMMUNITY 

or  rice,  and  lard,  is  usually  included  in  the  diet,  with 
few  vegetables  and  little  fruit,  and  often  the  children 
suffer  from  constipation  because  of  this  excess  of 
starch. 

Very  often  bringing  a  child  back  to  normal  health 
and  development  is  only  a  matter  of  readjusting  diet. 
With  a  slight  knowledge  of  their  predilections  this 
can  be  done.  They  do  not  need  to  be  encouraged  to 
eat  macaroni,  vermicelli,  or  spaghetti.  They  are 
quite  ready  to  eat  oatmeal  or  rolled  oats  if  these  are 
cooked  in  milk  and  with  raisins.  Undernourished 
children  should  be  given  soups  ^  and  milk,  plain  or 
in  custards.^  Other  recipes  for  children  may  be  found 
in  the  Appendix.^ 

A  constipation  diet  includes  vegetables,  cooked  in 
any  of  their  many  different  appetizing  ways,  and 
fresh  fruit  or  fruit  juices.  When  constipation  is  found 
among  Italians  it  is  usually  because  they  have  been 
financially  unable  to  secure  vegetables,  fruit,  and 
olive  oil,  and  have  lived  exclusively  on  macaroni, 
rice,  and  lentils. 

If  any  protein  is  to  be  allowed  to  an  Italian  with 
nephritis,  cheese  should  be  selected.  He  does  not 
miss  the  other  forms  of  protein  so  much.  He  uses 
very  little  meat  at  any  time;  eggs  are  used  as  thick- 
ening and  would  not  be  missed  if  another  thickening 
were  used,  but  cheese  furnishes  flavor  for  many 
dishes. 

Tuberculosis  patients  may  be  given  milk  in  the 
forms  prescribed  for  undernourished  children,  and 
eggs  in  soups.    The  Italian  people  are  not  in  the  habit 

^  See  Appendix,  recipes  1,  2,  3,  4.  "^  Ibid.,  recipes  5,  6. 

3  Ibid.,  recipes  7,  8,  9,  10,  11. 

256 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

of  using  soft  eggs,  although  they  have  many  recipes 
for  using  hard-boiled  eggs.  Patients  can  be  taught 
to  eat  them  poached  or  dropped,  and  served  with  a 
little  grated  cheese.  Sugar  may  be  prescribed  in 
fruit  compotes  or  in  stewed  fruits,  made  of  either 
fresh  or  dried  fruits.  Raisins  and  almond  paste  are 
other  forms  of  sweets. 

■Diabetic  patients  find  it  very  hard  to  go  without 
pasta  or  macaroni.  Among  the  poorer  people  it  has 
been  the  staple  at  every  meal.  Vegetables,  used  by 
them  in  many  combinations,  are  prescribed  for  this 
disease.  Tomatoes  may  be  scooped  out  and  have  an 
egg  dropped  in  each,  then  placed  in  a  small  dish  and 
baked  until  the  eggs  are  set.  Mushrooms  are  often 
chopped  and  baked  in  tomatoes.  Beans  of  all  kinds 
must  be  forbidden.  Often  the  use  of  mushrooms 
may  be  encouraged  in  their  place.  Endive  is  enjoyed, 
as  are  dandelions  and  spinach. 

If  Italians  can  secure  the  diet  they  prefer,  it  is 
usually  w^ell  balanced,  and  the  women  are  naturally 
good  cooks.  A  person  who  knows  the  native  dietaries 
can  help  them  to  adjust  themselves  successfully  to 
the  conditions  in  this  country. 

JEWISH   RELIGIOUS  RESTRICTIONS 

The  wanderings  of  the  Children  of  Israel  since  Bible 
times  have  made  them  an  international  race.  They 
have  known  all  countries,  and  adapted  themselves 
to  different  climates  and  products.  Because  of  these 
conditions  they  have  a  more  varied  dietary  than  any 
other  people.  They  know  the  Russian,  Polish,  Ger- 
man, Spanish,  and  Italian  foods,  and  have  adapted 

them  to  their  dietary  laws. 

257 


IMMIGRANT  HEALTH  AND  COMMUNITY 

It  is  essential  that  the  Jewish  dietary  laws  be 
understood  by  all  who  attempt  medical  or  social 
work  among  orthodox  Jews.  They  are  embedded 
deep  in  their  religion  and  custom.  Among  no  people 
is  infringement  of  them  so  unthinkable  and  of  such 
grave  consequence.  A  useful  paper  by  Mrs.  Mary 
L.  Schapiro,  giving  the  essential  laws,  should  be  con- 
sulted in  this  connection.^  Only  a  brief  summary  is 
included  here. 

The  prohibitions  on  Jewish  diet  are  of  three  kinds: 
on  the  kind  of  food;  on  the  preparation  of  food;  and 
on  the  time  different  foods  may  be  used.  The  only 
meat  that  can  be  used  is  that  from  clean  animals, 
"quadrupeds  that  chew  the  cud  and  also  divide  the 
hoof."  They  must  have  been  healthy  and  killed  in 
a  certain  way.  Only  fish  having  "fins  and  scales," 
and  birds  which  are  "not  scavengers  or  birds  of  prey," 
can  be  eaten.    Suet  is  forbidden,  but  not  fat. 

There  are  many  restrictions  on  the  preparation  of 
different  foods.  The  most  important  is  the  absolute 
prohibition  against  cooking  meat  and  milk  together 
or  eating  such  mixtures.  This  rule  is  rigidly  adhered 
to,  and  in  its  present  application  necessitates  the  use 
of  a  complete  double  equipment  of  dishes  and  uten- 
sils. Since  this  rule  is  regarded  as  one  of  the  most 
important,  one  can  understand  why  butter  or  milk 
sauces  are  refused  at  meals  with  meat.  It  occasions 
the  home-economics  teacher  a  great  deal  of  trouble 
in  planning  menus.  Meat  and  fish  are  another  com- 
bination that  must  not  be  cooked  together. 


1  Mary L,  Schapiro,  "Jewish  Dietary  Problems,"  The  Journal  of 
Home  Economics,  vol.  xi,  no.  2,  February,  1919.  An  extract  is 
included  in  the  Appendix. 

258 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

In  prescribing  diets  for  the  Jewish  people  it  is  help- 
ful to  remember  that  all  foods  may  be  classified  under 
three  heads:  (1)  Meat;  (2)  milk  and  its  products; 
(3)  neutrals.  Meat  and  milk  are  never  mixed.  Neu- 
trals may  be  used  with  meat  or  with  milk  products, 
but  never  with  both  in  the  same  meals. 

In  addition  to  the  daily  food  restrictions  there  are 
periodic  holidays  that  must  be  strictly  observed  in 
the  diet.  No  food  can  be  cooked  on  the  Sabbath. 
"During  Passover  week  no  leavened  bread  or  its 
product,  or  anything  which  may  have  touched  leav- 
ened bread,  may  be  used."  This  means  there  is  a 
thorough  housecleaning  in  preparation  for  this  week 
and  a  sterilization  of  all  utensils.  "A  complete  new 
set  of  dishes  is  used  during  the  week."  In  addition 
there  are  several  fast  days  and  semifast  days  with 
special  restrictions. 

Some  indication  of  the  cosmopolitan  diet  of  the 
Jewish  people  may  be  had  from  the  following  quota- 
tion from  Mrs.  Schapiro's  study: 

From  Spain  and  Portugal  comes  the  fondness  of  the 
modern  Jew  for  olives  and  the  use  of  oil  as  a  frying  medium. 
The  sour  and  sweet  stewing  of  meats  and  vegetables  comes 
from  Germany.  The  love  of  pickles,  cucumbers,  and 
herrings  comes  from  Holland,  as  also  does  the  fondness  for 
butter  cakes  and  bolas  (grain  rolls);  from  Poland  the 
Jewish  immigrant  has  brought  the  knowledge  of  the  use  of 
lokschen  or  fremsel  soup  (cooked  with  goose  drippings), 
also  stuffed  and  stewed  fish  of  various  kinds.  From  Russia 
comes  kasha,  made  of  barley  or  grits  or  cereal  of  some  sort, 
which  is  eaten  instead  of  vegetable  with  meat  gravy. 
Blintzes  are  turnovers  made  of  a  poured  batter  and  filled 
with  preserves  or  cheese,  and  used  as  a  dessert.  Sholent, 
sometimes  called  kugel,  are  puddings  of  many  kinds,  such 
as  magan,  lockschen,  farfil.    Zimes,  or  compotes  of  plums, 

259 


IMMIGRANT  HEALTH  AND  COMMUNITY 

prunes,  carrots,  and  sweet  potatoes,  turnips  and  prunes, 
parsnips  and  prunes,  and  prunes  and  onions  are  all  pud- 
dings, and  come  from  Russia.  Zimes  of  apples,  pears, 
figs,  and  prunes  are  southern  Rumanian,  Galician,  and 
Lithuanian  as  well. 

The  Jews  have  derived  certain  dietary  habits  from 
their  religious  laws  and  their  long  international  ex- 
perience. The  dietary  restrictions  on  the  use  of 
butter  and  meat  at  the  same  time  limit  the  use  of 
vegetables,  so  that  the  Jewish  people  are  not  so  fond 
of  them  as  they  ought  to  be  for  their  own  physical 
well-being.  The  Jewish  housewives  utilize  a  small 
amount  of  fresh  meat  in  dozens  of  ways.  They  have 
long  known  how  to  use  honey,  molasses,  and  syrup, 
in  place  of  sugar.  Sugar  has  been  a  luxury  in  many  of 
the  countries  from  which  they  come.  They  have 
also  been  fond  of  rye,  barley,  oats,  and  buckwheat. 
These  cereals  are  used  in  both  puddings  and  soups. 
They  have  little  knowledge  of  stewed  fruits,  but  do 
have  many  kinds  of  rich,  preserved  fruits.  All  these 
highly  seasoned  foods  they  have  in  abundance,  and 
it  is  with  difficulty  that  a  taste  for  the  simpler  foods 
is  cultivated.  Probably  no  other  people  have  so 
many  kinds  of  "sours"  as  the  Jews. 

In  the  Jewish  sections  of  our  large  cities  there  are 
storekeepers  whose  only  goods  are  pickles.  They 
have  cabbages  pickled  whole,  shredded,  or  chopped 
and  rolled  in  leaves,  peppers,  string  beans,  cucumbers, 
sour,  half  sour,  and  salted,  beets,  and  many  kinds  of 
meat  and  fish.  This  excessive  use  of  pickled  foods 
destroys  their  taste  for  milder  flavors,  causes  irrita- 
tion, and  renders  assimilation  more  difficult. 

When  the  Jew  arrives  in  this  country  some  of  the 

260 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

limitations  of  his  diet,  if  unchanged  by  instruction, 
are  evident.  Many  of  them  pay  little  attention  to 
their  diet  during  the  week,  until  their  Sabbath. 
Then  on  Friday  night,  on  Saturday,  and  on 
Sunday — which  to  most  of  them  is  a  holiday — they 
have  a  feast  time.  On  Friday  all  the  cooking  is  done 
for  the  next  two  days.  Chickens  are  cooked,  soup 
made,  and  huclien  (cakes)  and  mehlspeise  (flour  mix- 
tures) prepared.  As  a  result  of  these  weekly  feasts 
many  of  the  Jews  eat  too  much,  or  else  have  not  a 
well-balanced  ration.  By  nature  the  Jews  are  an 
emotional  people.  A  slight  physical  discomfort  often 
sends  them  to  a  doctor  when  the  readjustment  of 
their  diet  would  produce  a  cure. 

The  Jewish  children  suffer  from  too  many  pickles, 
too  few  vegetables,  and  too  little  milk.  Enuresis  is 
quite  common  among  these  children,  induced  by  the 
highly  spiced  foods  in  their  diet  and  the  pickles  eaten 
at  and  between  meals. 

For  undernourished  children  among  the  Jews,  it 
is  necessary  not  only  to  urge  the  use  of  milk,  but  to 
plan  when  it  may  be  taken,  as  it  cannot  be  taken  at 
the  same  meal  with  meat.  Therefore  midmorning 
and  midafternoon  meals  of  milk  must  be  introduced. 
This  is  impossible  for  the  children  who  eat  in  school, 
unless  there  is  a  school  lunch. 

Vegetables  are  usually  needed  in  greater  abun- 
dance. These  may  be  eaten  in  borsch,  a  favorite  soup 
much  like  our  vegetable  soup,  but  this  does  not  give 
them  in  very  large  portions.  Therefore,  a  menu 
should  be  planned  to  show  how  they  may  be  com- 
bined with  other  foods.    If  served  with  a  white  sauce 

or  butter,  vegetables  cannot  be  eaten  with  meat,  but 

18  261 


IMMIGRANT  HEALTH  AND  COMMUNITY 

they  can  be  eaten  at  the  noon  meal  or  lunch  with 
bread.  Creamed  vegetable  soups  also  may  be  given 
in  this  way,  but  never  at  the  same  meal  with  meat. 

In  the  treatment  of  constipation,  which  is  very 
frequent,  six  glasses  of  water  a  day  are  prescribed  *'  to 
kasher  the  intestines,"  cereal  pudding,  or  krupnick,  is 
given,  also  rye  bread  or  "Jewish  black  bread,"  and 
borsch  once  a  day.  The  recipes  for  krupnick  and 
borsch  are  to  be  found  in  the  Appendix.^ 

Many  Jews  have  diabetes.  When  prescribing  for 
them,  one  has  not  only  to  give  a  new  dietary,  but 
also  to  teach  new  ways  of  cooking  the  foods  allowed. 
For  example,  they  are  accustomed  to  cooking  vege- 
tables in  small  quantities,  with  beef;  but  for  the 
diabetic  this  is  excluded,  and  new  recipes  must  be 
introduced.  All  five  and  ten-per-cent  carbohydrate 
vegetables  may  be  served  with  drawn  butter,  white 
sauce,  or  a  hollandaise  sauce,  or  with  salt  and  a 
small  portion  of  lemon  juice  or  vinegar.  Green 
peppers  stuffed  with  vegetables  make  a  pleasant 
variety.  Liver,  which  is  frequently  used,  must  not 
be  allowed  in  the  diet.  The  patient  must  be 
warned  not  to  eat  during  Passover  mazzah,  or  un- 
leavened bread  made  of  flour,  salt,  eggs,  and  water, 
in  the  form  of  large  crackers.  Eggs  baked  in  spinach, 
or  scrambled  with  mushrooms,  may  be  eaten.  The 
Jewish  people  are  fond  of  the  flavor  of  almond 
omelet,  instructions  for  making  which  are  in  the 
Appendix.^ 

In  cases  of  nephritis,  the  use  of  all  pickled  foods 

and  "sour  salt"  should  be  discouraged.    Almost  all 

their  soups  are  low  in  protein.    Many  of  their  meat 

1  See  Appendix,  recipes  12,  13.  ^  Ihid.,  recipe  14. 

262 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

dishes  have  little  meat  in  them,  as,  for  example,  bitki, 
or  Hamburg  steak. ^  Both  kascha  and  schavel  are 
dishes  that  can  be  recommended  and  enjoyed.^ 

The  diet  for  a  Jewish  tubercular  patient  would 
have  less  carbohydrate  and  more  protein  than  is 
usually  found  in  the  Jewish  daily  dietary.  Milk  and 
eggs  may  be  given  between  meals  in  both  the  mid- 
morning  and  the  midafternoon,  and  before  bedtime. 
This  would  not  interfere  with  their  eating  meat 
at  lunch  and  dinner.  The  staple  borsch  may  be 
used,  made  without  meat,  and  with  the  addition  of 
sour  cream.  Sour  cream  is  a  favorite  dressing  for 
berries  or  fruit  and  may  be  used  freely  by  these 
patients. 

For  these  diets  the  American  way  of  preparing 
certain  foods  should  be  taught.  The  Jews  like  to 
scramble  their  eggs  with  vegetables  ^  or  bake  them 
in  a  nest  of  vegetables.  The  process  of  poaching  or 
**  dropping  "  eggs  is  unknown.  A  "  dropped  "  egg  was 
prescribed  for  a  patient  at  a  certain  food  clinic,  ^^^len 
it  was  explained  that  an  egg  was  broken  and  its  con- 
tents dropped  into  hot  water,  he  shook  his  head  and 
said,  "Oh  no!  I  lose  my  egg;  he  get  all  mixed  with 
the  water.'*  When  he  was  taken  to  the  stove  and 
saw  an  egg  poached,  he  stood  in  wonder  and  admira- 
tion. He  said,  *'I  go  home  tell  my  w^ife;  she  never 
knowed  that."  Since  then  many  mothers  and  even 
children  have  been  shown  in  this  same  clinic  how  to 
poach  eggs. 

All  cereals  must  be  tested  as  follows:  "Place 
them    on    a    hot    plate.      If    no    worms    or    other 

^  See  x\ppendix,  recipe  15.  ^  Ibid.,  recipes  16,  17. 

3  Ibid.,  recipe  18. 

263 


IMMIGRANT  HEALTH  AND  COMMUNITY 

insects  appear  they  are  fit  to  be  eaten;  if  not  fit 
they  must  be  thrown  away."  The  cereals  used  by 
the  Jewish  people  are  barley,  oats,  buckwheat,  and 
rice.  These  are  baked  in  puddings  and  eaten  with 
meat.  Children  soon  learn  to  eat  cereals  boiled  with 
milk,  and  will  learn  more  easily  if  raisins  are  added. 
The  making  of  all  kinds  of  milk  dishes,  from  a  plain 
boiled  or  baked  custard  to  a  Bavarian  cream,  will 
have  to  be  taught.  The  Jewish  housewife  has  had  to 
adapt  herself  a  number  of  times  to  new  foods  and  their 
preparation,  each  time  remembering  her  dietary  laws 
and  arranging  the  recipes  to  conform  to  them.  This 
fact  makes  her  an  apt  pupil. 

PEOPLE    OF   THE   NEAR    EAST 

The  Armenians,  Syrians,  Turks,  and  Greeks  are  in- 
teresting peoples.  With  their  love  for  friend  and 
neighbor,  creators  of  works  of  art,  dwellers  in  the 
out  of  doors,  they  have  much  to  give  to  any  country. 
In  the  matter  of  preparing  food  we  can  well  profit 
by  knowledge  of  their  ways.^ 

The  majority  of  those  who  come  to  America  lived 
in  their  native  lands  in  the  open  country  among  the 
foothills  or  on  the  high  table-lands.  A  minority  dwelt 
in  the  smaller  cities. 

Early  in  March,  in  the  home  country,  the  whole 
family  changes  its  mode  of  living  from  indoors  to 
out  in  the  open.  This  is  the  season  for  plowing  and 
planting,  meals  are  prepared  and  eaten  out  of  doors, 

^  Comparison  at  some  points  may  be  made  with  the  Mexicanst 
whose  dietary  problems  deserve  special  study.  See  "Dietary 
Studies  of  Mexican  Families  in  New  Mexico,"  1897  {Bulletin  W 
of  the  United  States  Office  of  Experiment  Stations). 

264 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

and  the  evenings  are  spent  under  the  great  canopy 
of  blue  and  gold,  with  the  family  and  relatives  telling 
the  news  of  the  day  and  exchanging  stories.  Some 
of  these  stories  have  been  related  many  times  before, 
but  their  familiarity  only  makes  them  more  in- 
teresting. 

These  people  practically  live  out  of  doors,  working 
in  the  fields  or  harvesting  their  supplies,  until  late 
in  November.  Then  they  take  up  different  lines  of 
craft  work.  Many  pieces  of  copper  and  brass  are 
tooled  and  etched  during  the  winter  months.  Some 
of  their  wonderfully  beautiful  rugs  are  woven  then. 
A  pleasant  pastime  for  the  older  women  is  dyeing 
the  yarn  with  the  gathered  vegetables,  mixing  a  little 
of  this  color  and  a  little  of  that  color  to  get  just  the 
shade  to  harmonize  with  the  design  in  the  mind  of 
the  weaver.  It  is  difficult  to  distinguish  between 
work  and  recreation  among  these  people. 

During  the  farming  season  they  raise  sheep  for 
food  and  clothing;  goats  and  cows  for  milk,  butter, 
and  cheese;  chickens,  ducks,  and  geese  for  eggs; 
and  grains,  vegetables,  fruits,  and  berries  in  abun- 
dance. Their  wheat  is  threshed  in  the  fall,  then  taken 
to  the  one  neighborhood  caldron,  where  it  is  boiled 
"until  all  germs  are  killed,"  and  spread  out  on  great 
sheets  of  cloth  to  dry  in  the  sun.  After  it  has  dried 
it  is  ground  between  two  great  stones  to  different 
degrees  of  fineness.  This  grain  is  used  in  many  dif- 
ferent ways;  it  is  even  burned  as  incense. 

Olives  are  pickled,  both  ripe  and  green,  and  some 
are  salted.  Wines  and  raisins  are  made  from  grapes 
and  the  leaves  of  the  grapevines  are  salted,  to  be 
used  later  for  wrapping  dolmas.     Figs,  dates,  and 

265 


IMMIGRANT  HEALTH  AND  COMMUNITY 

other  fruits  are  preserved  in  sugar.  Potatoes, 
squashes,  onions,  garlic,  and  other  vegetables  are 
put  in  pits  in  the  ground.  At  least  three  lambs  are 
salted.  In  the  Orient,  lamb  is  the  principal  meat 
used. 

Rice  has  a  large  share  in  the  daily  menu.  The  use 
of  nuts  with  rice  and  meat  adds  attractiveness  to 
the  diet.  Pine-cone  seeds,  or  fustucky  hazelnuts,  or 
fanducks,  chestnuts,  or  kestanchy  pistachio  nuts,  and 
coriander  seeds  are  some  of  the  seeds  referred  to  in 
Oriental  recipes.  Cardamon  seeds  are  frequently 
added  to  coffee.  Chick  peas,  or  nohond,  sl  product  of 
Greece  and  Turkey,  and  fava,  pakla,  or  horse  beans, 
two  of  the  leguminous  plants  used,  have  a  high  food 
value.  There  are  various  wheat  preparations  in 
which  the  grain  appears  in  different  forms. 

In  Eastern  cookery  not  a  single  dish  is  dependent 
on  the  extravagant  use  of  expensive  ingredients; 
every  dish  is  dependent,  and  very  much  so,  on  the 
flavor  of  each  article  used  in  its  making.  Oriental 
food  is  not  highly  spiced  or  flavored,  but  it  is  a  very 
fat  diet.  Butter  is  not  eaten  on  bread,  the  fat  in  the 
food  preparations  being  sufficient. 

The  breakfast  of  these  Easterners  consists  of  black 
coffee  and  bread  for  the  adults  and  goats'  milk  and 
bread  for  the  children.  In  some  families  cracked 
wheat  boiled  with  milk  is  used  as  a  cereal 

The  noon  meal  may  be  matzaun,  or  curdled  milk, 
with  a  "dressing"  of  pilaf.  Matzaun  or  yoghourt  ^  is 
the  famous  beverage  or  soup  of  the  Orient.  It  is 
served  either  hot  or  cold  or  sweetened  with  sugar. 
It  is  as  valuable  in  their  diet  as  buttermilk  in  ours. 

^  See  Appendix,  recipe  19. 

266 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

For  the  dinner  or  evening  meal,  shish  kibab — lamb 
cut  in  walnut-sized  pieces  and  roasted  on  skewers — 
is  a  favorite  meat  dish.  All  vegetables  are  first  fried 
in  a  small  amount  of  olive  oil  or  other  fat,  then  boiled 
in  meat  stock.  Sometimes  tomato  is  added  to  give 
more  flavor.  Okra  is  never  slimy,  and  vegetables 
lose  their  green  taste  when  first  cooked  in  oil  or  other 
fat. 

When  these  people  settle  in  America  the  men  are 
seldom  laborers;  almost  all  choose  commercial  occu- 
pations. Many  of  our  finest  fruit  stores  are  owned 
by  Greeks,  Armenians,  or  Syrians.  They  usually 
start  with  a  pushcart  of  fruit,  frequently  bananas, 
and  gradually  work  up  a  trade,  buy  a  horse  and 
wagon,  then  establish  a  small  store.  Others  are 
waiters  in  restaurants  or  have  shoeblacking  stands. 
Some  sell  antique  rugs,  or  clean  and  repair  them. 
Because  of  their  indoor  occupations,  their  incomes 
are  more  regular  than  the  incomes  of  those  who  are 
laborers  or  do  other  seasonal  work. 

There  are  comparatively  few  Eastern  women  over 
here.  Often  an  Easterner  and  his  wife  run  a  restau- 
rant and  board  a  number  of  men.  Sometimes  a 
bulletin  board  is  hung  in  these  places  upon  which 
letters  received  from  home  are  posted  for  others 
besides  the  recipient  to  read.  Eating  at  these  res- 
taurants is  a  social  occasion;  the  food  is  well  cooked, 
although  the  service  lacks  some  of  the  conventionali- 
ties of  this  country. 

In  this  country  these  Easterners  continue  their 

dietary  customs  to  a  large  extent.    It  was  interesting 

to  find,  during  the  war,  that  they  were  still  able  to 

secure  wheat  in  its  different  degrees  of  coarseness. 

267 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Fruit,  however,  is  not  so  plentiful,  and  milk  becomes 
a  luxury.  A  Syrian  woman  who  had  tubercular 
glands  was  advised  to  use  one  quart  of  milk  a  day. 
She  showed  no  improvement,  after  being  treated  for 
some  time,  and  it  was  discovered  that  she  had  not 
had  the  milk.  When  asked  why  she  did  not  take  it, 
she  said:  "The  milk  come  in  a  bottle;  in  my  country 
I  get  it  from  the  goat.  The  doctor  ordered  milk,  and 
I  do  not  know  what  else  is  in  the  bottle;  there  must 
be  something  besides  milk,  to  make  it  cost  so  much." 
All  was  explained,  and  milk  ordered  for  the  patient. 
She  began  to  improve,  and  then  she  was  convinced 
that  although  we  have  an  expensive  way  of  obtain- 
ing milk  it  has  the  same  virtue  as  at  home. 

Among  the  Syrians,  Armenians,  Greeks,  and 
Turks  we  usually  find  the  children  well  nourished, 
with  plenty  of  growth  material  and  mineral  matter 
in  their  diets.  They  do  not  have  milk  and  fruit  in 
as  large  quantities  as  they  should,  because  of  the 
expense. 

The  undernourished  children  need  more  milk 
added  to  their  diet.  Wheat  is  used  extensively, 
either  whole  or  cracked;  it  is  cooked  in  water  until 
nearly  done,  then  milk  is  added  for  the  last  few 
minutes'  cooking.  Even  the  candy  or  sweetmeats, 
called  medley y  is  made  with  wheat. ^  The  green-leaved 
vegetables  are  not  used  in  cream  soups,  but  are 
cooked  in  stock.  This  must  be  remembered  in  diets 
for  children. 

A  Greek  boy,  a  patient  at  a  dispensary,  was  re- 
ferred to  a  food  clinic  for  a  constipation  diet.  When 
questioned  about  the  delicious  orange  compotes  the 

1  See  Appendix,  recipes  20,  21. 

268 


IMIVIIGRANT  DIETS  AND  AMERICAN  FOOD 

Greeks  usually  have  two  or  three  times  a  day  on 
their  tables  at  home,  he  said:  "Oh  yes!  My  mother 
makes  it,  but  she  keeps  it  for  company.  AVhen  she 
is  out  I  crawl  in  the  window  and  eat  some  on  my 
bread.  Oranges  cost  a  lot  for  boys,  my  mother  says." 
Dried  as  well  as  fresh  fruits  may  be  prescribed,  but 
they  should  be  as  compotes,  not  "stewed."  ^  The 
national  dish  of  the  Turks  is  pilaf;  of  the  Armenians, 
herissa.  Both  of  these  are  good  foods  for  the 
children.^ 

When  vegetables  are  prescribed,  it  is  well  to  re- 
member that  the  Oriental  cooks  them  with  olive  oil. 
They  are  known  as  basidis,  and  are  used  extensively 
cooked  with  meat  or  in  olive  oil,  or  both.  One  of  the 
best  dishes  for  a  patient  with  constipation  is  cabbage 
with  meat.^  Another  dish  equally  valuable  is  tureli 
ghuvedge,  or  mixed  vegetables  with  meat.* 

Nephritis  seems  to  be  almost  unknown  among 
these  people.  A  patient  may  have  any  of  their 
cereal  dishes  made  of  wheat  or  rice  and  any  of  their 
green  vegetables  cooked  in  olive  oil.  Suggestive 
combinations  for  them  are  given  in  the  Appendix.^ 

Because  of  the  large  amount  of  rice  and  wheat  used 
in  Oriental  dishes,  it  is  difficult  to  plan  a  diet  for  a 
diabetic  patient.  In  prescribing  low-carbohydrate 
vegetables  cooked  in  olive  oil  and  lamb  and  chicken 
cooked  on  skewers,  one  can  be  sure  no  rice  or  wheat 
is  used. 

The  tuberculosis  patient  should  have  black  coffee 
replaced  by  milk  in  his  diet.    Several  milk  dishes  are 


^  See  Appendix,  recipe  22.  ^  Ibid.,  recipes  23,  24* 

^  Ibid.,  recipe  25.  ^  Ibid.,  recipe  26. 

^  Ibid.,  recipes  27-30. 

269 


IMMIGRANT  HEALTH  AND  COMMUNITY 

given  in  the  Appendix.  Tzouvatzegh,  the  Armenian 
egg  milk  toast,  is  very  good.^  Matzaun  is  always 
popular  and  may  be  combined  with  eggs.^  A  favorite 
egg  dish  is  made  with  orange  and  is  called  sudeli 
youmourta.^  Buttered  bread  is  often  served  with  a 
pitcher  of  hot  milk,  and  eaten  as  we  eat  bread  and 
milk. 

The  people  of  the  Near  East  seem  to  have  a  greater 
knowledge  of  food  combinations  than  any  other 
people.  It  is  generally  supposed  that  their  cookery 
is  spicy,  but  it  can  be  seen  from  their  recipes  that 
the  cooking  is  rich,  not  in  condiments,  but  because 
of  the  number  of  ingredients. 

POLES   AND    OTHER    SLAVIC    PEOPLE 

The  Poles  come  from  a  northern  climate,  where  the 
summers  are  not  so  long  as  the  winters.  Very  few 
people  from  the  cities  of  Poland  come  to  America. 
Those  we  find  here  are  the  peasant  class.  On  their 
farms  they  raised  the  grains  and  vegetables  that 
develop  during  a  short  season — beans,  carrots,  tur- 
nips, parsnips,  cabbage,  lettuce,  and  other  summer 
vegetables.  Tomatoes  are  not  raised  nor  are  they 
known  outside  of  Warsaw.  They  raise  stock  from 
which  they  get  milk  and  meat. 

Meat  has  a  prominent  place  in  the  Polish  diet — 
beef,  veal,  and  pork  being  the  kinds  in  common  use. 
These  are  roasted  plain  or  boiled  in  various  com- 
binations. Pork  is  perhaps  the  favorite,  and  they 
have  many  ways  of  making  it  into  sausage  and  of 
smoking  it.    When  smoked  it  is  often  covered  with 

^  See  Appendix,  recipe  31.  ^  Ihid.,  recipe  32. 

2  Ihid.,  recipe  33. 

270 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

mace  to  add  flavor.  This  is  true  not  only  among  the 
Poles,  but  among  other  Slavic  people.  Pork  is  fre- 
quently used  with  beef  and  made  into  puddings  or 
loaves.  In  the  winter  the  only  fresh  meat  used  is 
game,  and  it  is  customary  to  roast  this  over  an  open 
fire.  Eggs  instead  of  meat  form  the  dinner  dish  on 
Wednesday  and  Friday.  Sometimes  chickens  or 
ducks  are  used. 

Fish  is  used  fresh  in  summer  and  pickled  in  winter. 
It  is  rarely  preserved  by  salting.  Fish  is  boiled  or 
baked,  but  for  special  occasions  the  best  cooks  prefer 
to  make  it  into  cutlets.  These  are  made  of  cooked 
fish  blended  with  a  sauce  or  gravy,  shaped  into  cut- 
lets, and  fried  or  baked  with  a  sauce  or  gravy. 

Potatoes  are  served  at  almost  every  meal.  The 
preferred  grain  among  all  the  Slavic  people  is  barley. 
The  Poles  use  corn  meal  and  oats  also. 

"VMien  the  man  of  the  family  gets  his  first  job  in 
this  country,  it  is  as  a  laborer,  sometimes  building 
our  railroads,  bridges,  or  subways.  He  generally 
carries  his  noon  luncheon  to  work  and  it  consists  of 
bread  broken  from  a  loaf,  either  round  or  oblong, 
according  to  which  shape  fitted  the  oven.  With  this 
he  may  have  some  bizoSy  if  he  is  Polish.  Bizos  is 
made  of  two  kinds  of  sausage,  red  and  white,  sauer- 
kraut, tender  beef,  pork,  and  barley,  all  boiled  to- 
gether into  a  thick  pudding.  It  is  sliced,  and  eaten 
cold  or  warm.  In  his  own  country  bizos  was  one  of 
the  luncheon  meats  taken  on  hunting  trips,  and  as 
the  laborer  sits  on  the  curb,  or  out  along  the  railroad 
he  is  helping  to  build,  his  enjoyment  of  the  lunch  is 
accompanied  by  memories  of  those  hunting  expedi- 
tions and  the  friends  who  were  with  him. 

271 


IMMIGRANT  HEALTH  AND  COMMUNITY 

The  family  diet  slowly  changes  from  flour  gruel 
and  potatoes,  with  coffee,  for  breakfast,  to  more 
American  dishes.  They  continue  the  custom  of  hav- 
ing eggs  for  dinner  on  Wednesday  and  Friday  as 
long  as  they  are  able  to  afford  it.  In  winter,  because 
of  the  high  price  of  eggs  or  because  the  man  is  out 
of  work,  they  must  find  a  substitute  or,  what  is  more 
frequent,  go  without.  Flaxseed  oil  is  their  favorite 
fat.  That  is  hard  to  find  here,  and  this  necessitates 
learning  to  use  some  of  the  vegetable  oils  which  we 
have. 

The  Polish  children,  and  those  of  the  other  Slavic 
people,  come  from  sturdy  stock.  Upon  arrival  in 
this  country  they  have  round,  well-shaped  heads, 
rosy  cheeks,  and  strong  bodies.  With  their  kerchiefs 
over  their  heads  they  make  fascinating  pictures  of 
health.  They  have  had  an  abundance  of  milk  and 
fresh  air  in  their  own  countries. 

Here  they  live  at  first  in  crowded  districts.  Milk 
is  counted  as  a  drink,  not  something  to  eat;  there- 
fore, because  the  family  income  is  small,  it  is  left 
out  of  the  diet  almost  entirely.  If  these  children  are 
fortunate  enough  to  belong  to  Polish  families  that 
have  saved  and  bought  land  in  the  country,  for 
tobacco  or  onion  farms,  they  have  goats'  milk,  vege- 
tables, and  fruit.  Otherwise  they  eat  what  the  grown- 
ups have,  and  they  pay  the  price.  Sometimes  they 
are  constipated,  with  accompanying  ill  feelings; 
sometimes  they  are  under  weight. 

In  cases  of  undernourishment  among  the  children 
it  is  necessary  with  the  Slavs,  as  with  all  other  foreign- 
born  people,  to  help  plan  for  milk  in  the  food  budgets. 

Among  their  soups,  children  may  have  rosolzlazan- 

272 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

kamt,  a  consomme  with  eggs  dropped  in  it.  Eggs 
are  beaten  as  for  scrambled  eggs,  and  dropped  into 
the  hot  soup  by  small  spoonfuls  just  before  serving. 
They  may  also  have  chicken  soup,  or  krupnik  palski, 
which  is  prepared  with  barley.  Cereals  are  eaten  not 
only  for  breakfast,  cooked  in  milk,  but  in  soups  and 
baked  and  served  with  meat.  As  vegetables  are  sel- 
dom cooked  and  served  without  meat,  it  is  necessary 
not  only  to  prescribe  them,  but  also  to  show  how  to 
make  purees  and  to  cook  plain  vegetables.  Kieselle 
is  one  of  the  desserts  children  like;  it  is  made  of 
blackberries,  raspberries,  or  black  concord  grapes.^ 

A  constipation  diet  is  a  very  easy  one  to  find  for 
these  people,  as  they  are  accustomed  to  eating  many 
vegetables.  Szynka  pieczona  zkasza,  ham  roasted 
with  cabbage,  or  rozbiantere  dusgony,  roast  fowl  with 
vegetables,  illustrates  how  inseparable  are  their  meats 
from  their  vegetables.  Dusgony,  or  vegetables,  they 
welcome  on  a  diet  list.  Coarse-grained  cereals  they 
use,  as  kasga,  boiled  in  milk  or  baked  in  water,  with 
milk  and  fat  added  during  the  baking  to  give 
moisture. 

The  diabetic  patient  finds  consolation  in  the  num- 
ber of  fish  dishes  known  to  the  Poles  and  Russians. 
Ryha  wgalarecie,  or  fish  in  jelly,  is  much  enjoyed. 
The  jelly  is  made  with  lemon,  and  the  first  layer 
often  has  chopped  cabbage  or  celery  in  it.  When 
this  is  set  the  fish,  already  boiled,  is  placed  upright 
in  it,  and  covered  with  more  cooled  jelly.  Another 
favorite  dish  is  made  of  the  gelatin  from  the  feet  of 
the  pig,  with  meat  from  the  hocks.  Ciely,  or  veal 
roasted  or  made  into  cutlets,  may  be  used;  also  pork, 

^  See  Appendix,  recipe  34. 

273 


IMMIGRANT  HEALTH  AND  COMMUNITY 

or  wieprzonyy  prepared  in  a  number  of  ways.  Sledy 
pocztomy  or  maatjis  herring  is  often  used  for  supper. 

For  nephritis  patients,  it  is  hard  to  separate  pro- 
tein from  vegetables.  Their  vegetable  soups,  made 
thick  with  vegetables,  are  useful  in  such  a  diet.  Zupa 
jarzynowa  is  vegetable  soup  made  with  a  foundation 
of  chicken  stock  and  any  or  all  kinds  of  seasonable 
vegetables.  Soup,  or  rosal,  with  makoronom,  or  noo- 
dles, cannot  be  included,  but  horszoz  zabillang  can  be 
given.  This  is  a  soup  made  by  boiling  both  the  tops 
and  the  roots  of  beets  and  adding  fat  and  sour  cream. 

Tuberculosis  patients  will  benefit  from  the  smie- 
tanie,  or  cream  sauces,  which  are  used  for  vegetables, 
meats,  and  game.  Ovsyanka  is  a  very  good  oatmeal 
soup.^  Flaxseed  oil  with  a  small  amount  of  lemon 
juice  is  a  favorite  salad  dressing. 

APPLICATION   TO   HEALTH    WORK 

From  our  studies  of  dietary  backgrounds  it  is  ap- 
parent that  a  family  coming  to  this  country  from  a 
wholly  different  environment  is  under  an  enormous 
handicap  in  attaining  a  satisfactory  diet,  particu- 
larly when  the  income  is  small.  Moreover,  doctors, 
nurses,  social  workers,  and  even  dietitians  generally 
lack  knowledge  of  the  native  diets  and  food  habits 
of  the  foreign  born. 

Against  these  limitations  must  be  set  the  fact  that 
a  large  number  of  the  foods  of  foreign-born  peoples 
are  well  adapted  to  their  physical  needs,  and  that 
most  of  these  can  be  obtained  in  this  country. 
Furthermore,  dietary  errors  are  largely  due  to  dis- 

^  See  Appendix,  recipe  35. 

274 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

turbance  of  balance  in  the  diet  because  of  change  of 
environment  or  new  scales  of  prices.  The  problem 
before  the  dietitian  is  not  so  much  to  introduce  a 
complete  "American"  dietary,  as  it  is  to  restore  the 
former  dietary  balance  by  supplying  lost  elements. 

KNOWLEDGE    OF    niMIGRANT's    FOOD    ESSENTIAL 

Knowledge  of  the  foods  of  the  foreign  born  and  of 
their  native  dietaries  is  the  foundation  of  all  success 
in  this  endeavor;  it  is  a  necessity  in  dealing  with 
many  specific  problems  of  health  or  of  disease,  and 
it  is  invaluable  as  a  means  of  mutual  understanding 
and  sympathy  between  the  American  born  and  the 
immigrant.  "The  way  to  a  man's  heart  is  through 
his  stomach."  The  soul  of  a  family  may  be  reached 
through  the  daily  chores  of  the  household. 

The  following  story  illustrates  how  a  sympatheti- 
cally prescribed  diet,  recognizing  the  value  of  familiar 
national  foods,  can  aid  in  winning  the  friendship  of 
individuals.  A  Russian  woman  was  asked  to  inter- 
pret for  a  Ukrainian  at  a  food  clinic.  She  was  not 
much  interested  at  first,  but  when  some  of  her 
national  foods  were  mentioned  she  looked  up,  and 
said  to  the  dietitian,  "I  only  been  here  in  this  coun- 
try three  years,  but  you  my  sister."  She  then  urged 
the  patient  to  use  the  food  prescribed,  and  was  much 
more  diligent  thereafter  in  her  own  regimen. 

NEED    FOR   PRINTED    MATERIAL 

Certain  particular  needs  become  evident  as  the  result 
of  this  incomplete  and  tentative  survey.    There  is  a 

demand  for  printed  material  for  professional  workers, 

275 


IMMIGRANT  HEALTH  AND  COMMUNITY 

such  as  visiting  nurses,  dietitians,  domestic-science 
teachers,  and  social  workers.  This  material  should 
be  published  in  several  forms,  as : 

(a)  A  textbook  for  colleges  and  hospitals,  in  which 
young  women  are  trained  as  domestic-science  teach- 
ers, dietitians,  or  nurses,  including  a  list  of  foods  and 
the  recipes  of  foreign  diets  corresponding  to  weU- 
balanced  American  diets. 

(6)  A  book  somewhat  less  formal  in  character,  for 
dietitians,  visiting  nurses,  and  medical-social  work- 
ers, covering  the  diets  of  the  different  nationalities 
and  races  in  relation  to  health,  with  particular  in- 
structions in  the  preparation  of  food,  as  well  as  de- 
scriptive matter  and  general  principles. 

(c)  Single  reprints  in  leaflet  form  of  this  material 
for  each  nationality  or  race,  each  reprint  containing 
some  statement  of  general  principles,  a  brief  account 
of  the  dietary  background  of  the  race  group,  and 
practical  recipes.  This  might  not  only  be  available 
for  the  worker,  but  could  be  given  with  discretion 
to  the  foreign  born. 

Published  material  which  would  enlighten  Ameri- 
cans regarding  the  practical  utility  and  en  joy  ability 
of  many  foreign  foods  could  be  widely  used.  A 
study  of  "Foreign  Foods  Which  Would  Improve  the 
American  Dietary"  would  be  an  Americanizing  agent 
of  practical  value  for  the  use  of  home-economic  sec- 
tions of  women's  clubs  and  similar  organizations. 
American  diet  would  be  improved  and  enriched,  and 
many  Americans  would  be  given  a  sympathetic  ap- 
preciation and  understanding  of  our  foreign-born 
population   through  the  practical   medium   of   the 

kitchen  and  dinner  table. 

276 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

The  great  practical  interest  which  everybody  has 
in  food  should  be  used  in  teaching  English.  There 
seems  to  be  need  for  the  preparation  and  publication 
of  an  American  home-making  primer,  telling  briefly 
and  simply  what  to  buy,  how  to  use  American  stoves 
and  American  utensils,  and  introducing  the  best 
American  foods  to  the  reader.  Such  a  primer  might 
be  especially  good  for  the  foreign  born  who  have  just 
learned  or  are  just  learning  English.  It  might  also 
be  printed  in  a  foreign  language  or  be  bilingual. 

INTERNATIONAL   MENUS   FOR   INSTITUTIONS 

An  international  menu  should  be  used  in  institutions 
of  all  kinds  receiving  any  number  of  foreign  born.  An 
international  menu  is  one  which  is  not  confined  to 
American  dishes,  but  which  cont-ains  each  day  at  least 
one  dish  especially  adapted  to  one  of  the  nationalities 
or  races  represented  among  the  patients.  This  would 
demonstrate  to  the  patients  that  the  dietitian  has 
considered  them  and  the  psychological  effect  would 
help  them  physically.  Thus  in  a  menu  for  an 
institution  with  many  different  race  groups,  a  char- 
acteristic Italian  dish  might  be  included  one  day,  a 
Polish  dish  another,  and  the  next  day  the  Jewish  or 
Russian  patients  might  be  remembered.  Such  a  menu 
need  not  make  the  diet  less  acceptable  to  the  native- 
born  Americans.  It  would  give  greater  variety  and 
would  help  the  dietitians  in  their  endless  search  for 
something  new.  So  all  would  be  better  satisfied  both 
physically  and  mentally. 

The  work  of  making  up  such  an  international  menu 
is  a  matter  of  practical  and  not  difficult  detail.    Die- 

19  277 


IMMIGRANT  HEALTH  AND  COMMUNITY 

titians  or  others  responsible  for  the  menus  in  hospitals, 
sanatoriums,  convalescent  homes,  restaurants  in  in- 
dustrial plants,  should  develop  something  of  this 
sort,  wherever  the  racial  constitution  of  their  people 
requires  it. 

The  diet  lists  used  by  medical  institutions,  such  as 
hospitals  and  dispensaries,  should  be  adapted  to  the 
people  as  well  as  to  the  diseases  which  are  treated. 
The  habitual  foods  of  the  nationality  or  race  dealt 
with  must  be  in  the  mind  of  the  person  who  prepares 
the  diet  list,  if  it  is  to  be  of  real  service.  This  means 
that  the  dietitians,  visiting  nutses,  or  social  workers 
who  handle  the  dietary  problems  of  the  patients 
should  have  some  knowledge  of  foreign  as  well  as 
of  characteristic  American  diet. 

The  average  visiting  nurse  or  medical  social-service 
worker  is  not  expert  in  dietetics  and  so  must  depend 
upon  the  advisory  dietitian  or  the  visiting  house- 
keeper. Dispensary  and  visiting-nursing  associations 
should  provide  themselves,  directly  or  through  the 
co-operation  of  some  other  organization,  with  at  least 
the  advisory  services  of  such  a  dietitian. 

FOOD   CLINICS   INDISPENSABLE 

Food  clinics,  in  which  dietitians  can  be  consulted  by 
nurses  or  general  workers,  and  to  which  patients  can 
be  sent  when  necessary,  are  needed  in  large  dispen- 
saries and  in  connection  with  the  Health  Centers 
which  are  now  being  established  so  rapidly  throughout 
the  country.  It  is  not  desirable  that  these  clinics 
should  be  confined  to  the  restricted  field  of  child 

nutrition. 

278 


IMMIGRANT  DIETS  AND  AMERICAN  FOOD 

A  dietitian  has  never  been  so  honored,  in  college  or 
out,  as  she  will  be  by  these  foreign-born  people  when 
they  realize  her  knowledge  of  their  familiar  foods. 
An  Armenian  storekeeper  found  a  fellow  countryman, 
a  chef  in  an  Armenian  restaurant,  suffering  from  in- 
digestion. He  said  to  him:  "You  come  with  me.  I 
take  you  to  the  smartest  woman  you  ever  knew.  She 
knows  our  foods,  she  tell  you  what  to  eat  you  feel 
better." 


Part  IV 
AMERICAN  AGENCIES  AND  METHODS 


XIII 

FIELD   WORK   WITH   THE    IMMIGRANT 

The  evolution  of  the  field  agent,  who  in  practice  is 
either  a  visiting  nurse,  a  social  worker,  or  both,  is  a 
most  significant  recent  development  in  medical  or- 
ganization. Fifteen  years  ago  there  were  a  few  hun- 
dred visiting  nurses  in  the  United  States;  to-day- 
there  are  probably  over  ten  thousand. 

The  field  agent  has  been  the  common  denominator 
in  the  series  of  campaigns  which  have  swept  the 
country  in  the  last  twenty  years,  directed  against 
some  disease  or  group  of  more  or  less  preventable 
diseases.  Each  of  these  has  been  initiated,  guided,  or 
pushed  by  national  and  by  local  organizations  formed 
for  the  purpose.  First  in  the  field  was  the  antitubercu- 
losis campaign.  There  followed  in  rapid  succession 
national  movements  to  reduce  infant  and  maternal 
mortality,  to  control  cancer,  to  control  and  prevent 
venereal  disease,  to  promote  school  hygiene,  dental 
hygiene,  and  mental  hygiene.  The  striking  fact,  ap- 
parent after  a  slight  survey  of  these  various  move- 
ments, is  their  common  dependence  for  practical  suc- 
cess upon  the  field  agent.  A  similar  development  may 
be  traced  in  the  social-service  departments  of  general 
hospitals  and  dispensaries. 

Through  the  field  agent  the  clinic  or  medical  center 
reaches  directly  into  the  homes  of  the  people.     She 

does  two  things — she  renders  service  and  she  educates. 

283 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Bedside  service  to  sick  people  brings  a  response  in 
gratitude  and  sympathy  which  lays  the  foundation 
for  effective  educational  work.  The  field  agent  means 
the  beginning  of  a  closer  relation  between  the  objects 
of  medical  and  health  work,  the  people,  and  the 
agents  of  such  work — the  doctors  and  administrators ; 
she  means  that  medical  and  health  work  ceases  to  be 
passive  and  begins  to  seek  out  its  subjects;  she  means 
the  beginning  of  localization,  making  a  democratic 
neighborhood  relation  possible  between  those  who 
serve  and  those  who  are  served. 

The  success  of  the  visiting  nurse  and  medical-social 
worker  in  various  practical  efforts  in  curative  and  pre- 
ventive medicine  illustrates  our  principle  that  suc- 
cessful service  must  include  the  study  of  people  as 
well  as  of  technique,  and  should  be  localized  as  thor- 
oughly as  possible  in  order  to  develop  personal  rela- 
tions on  a  democratic  basis. 

Hence  the  experience  of  field  agents  is  important  in 
developing  the  technique  of  health  work  with  the  foreign 
born.  What  are  the  problems  of  militant  health 
agencies  in  dealing  with  the  immigrant?  What  spe- 
cial problems  do  the  visiting  nurses  and  hospital  social 
workers  meet  in  the  immigrant's  home?  W^hat  meth- 
ods have  been  most  successful?  What  difficulties  are 
still  to  be  solved?  These  are  some  of  the  questions 
answered  by  nurses,  social  workers,  and  executives  of 
some  fifty  social-service  departments,  and  about  two 
hundred  tuberculosis  and  other  health  agencies. 

THE   PROBLEM   OF   APPROACH 

The  first  necessity  of  the  field  worker  is  to  establish 
contact  with  the  foreign-born  family.    In  many  cases 

^34 


FIELD  WORK  WITH  THE  IMMIGRANT 

these  are  recent  immigrants  who  speak  no  English. 
Her  object  is  to  get  them  to  do  something  or  allow 
her  to  do  something  for  them,  for  the  good  of  their 
health.  She  must  either  convince  them  of  the  worth 
of  her  recommendations  or  inspire  them  with  such 
confidence  in  herself  that  they  will  take  her  recom- 
mendations on  faith.  The  nurse's  most  obvious  dif- 
ficulty is  ignorance  of  the  foreign  language;  a  more 
fundamental  difficulty  is  ignorance  of  the  immigrant's 
social  backgrounds  and  point  of  view. 

The  use  of  the  nurse  of  foreign  birth  or  parentage 
would  seem  on  first  consideration  to  solve  both  diffi- 
culties.   One  association  writes  : 

We  had  a  Polish  nurse  who  was  very  helpful.  She  was 
Polish  born,  spoke  German,  French,  Swedish,  besides  under- 
standing a  good  many  of  the  dialects. 

Another  statement  comes  from  Denver,  Colorado : 

We  have  had  only  one  nurse  who  was  foreign  born  on 
our  staff.  She  was  Italian  and  of  average  ability,  but  very 
popular  with  her  patients. 

Further  examination,  however,  discloses  limitations 
to  this  service.  Comparatively  few  foreign-born  girls 
take  nurse's  training,  either  because  they  have  not  the 
prerequisite  education  or  because  other  vocations  take 
less  preparation  and  yield  a  quicker  return,  or  because 
national  customs  hold  personal  service  in  lower  regard 
than  clerical  work  or  teaching.  Among  nationalities 
where  marriage  is  considered  the  only  respectable  pro- 
fession for  women,  any  kind  of  paid  work  is  regarded 
as  demeaning. 

Moreover,  it  seems  to  be  a  question  whether  foreign 

birth  is  in  itself  an  advantage.    It  is  the  experience  of 

285 


IMMIGRANT  HEALTH  AND  COMMUNITY 

several  associations  that  nurses  of  foreign  birth  do 
not  possess  American  habits  of  personal  and  home 
hygiene  to  a  sufficient  extent  to  push  them  with  their 
patients  against  the  inertia  of  generations.  They  lack 
conviction  in  their  message  and  confidence  in  their 
pupils'  ability  to  change.  Sometimes  the  conviction 
is  present,  but  accompanied  by  contempt  of,  or  im- 
patience with,  their  compatriots.  On  the  other  hand, 
it  seems  logical  that  a  family  inclined  to  adopt  Ameri- 
can ways  would  prefer  to  learn  directly  from  a  native 
American.  Testimony  on  these  points  was  received 
from  a  number  of  places : 

We  have  had  one  or  two  [foreign-born  nurses]  and  our 
experience  has  been  that  the  families  did  not  care  for  them 
and  I  do  not  think  the  nurses  are  as  patient  with  people 
of  their  own  nationality  as  with  others. 

We  have  one  Polish  nurse  and  have  had  Italian  nurses, 
but  we  have  found  that  these  women  do  not  have  so  great 
an  influence  upon  their  own  nationality  as  does  an  American 
nurse. 

The  reason  English-speaking  nurses  do  better  work  than 
the  Spanish-speaking  is  that  their  environment  and  training 
have  given  them  an  opportunity  to  see  the  advantage  of 
their  work. 

Foreign-born  nurses  often  have  a  very  strong  in- 
fluence with  their  patients,  but  it  is  probable  that  they 
secure  this,  not  through  their  foreign  birth,  but 
through  their  knowledge  of  the  foreign  tongue  and 
customs. 

BARRIER   OF   LANGUAGE 

Native-born  nurses,  except  for  a  relatively  few,  must 
overcome  the  language  barrier  by  the  use  of  interpre- 
ters and  foreign-language  literature.     There  is  little 

286 


FIELD  WORK  WITH  THE  IMMIGRANT 

organized  provision  for  interpreters  in  this  country. 
Therefore,  the  nurse  must  depend  upon  whoever  can 
be  pressed  into  service  at  the  moment.  Most  fre- 
quently this  is  a  neighbor  or  a  child  of  the  household, 
rarely  a  paid  interpreter.  Interpretation  demands  so 
much  understanding,  conviction,  and  sympathy,  be- 
sides mere  translation,  that  it  is  not  surprising  to  find 
differences  of  opinion  as  to  whether  children  or  adults 
prove  more  satisfactory. 

The  case  against  the  adult  relative,  or  neighbor, 
may  be  stated  as  follows: 

The  question  of  a  paid  interpreter  has  been  the  most 
difficult  one,  for  it  is  almost  impossible  to  obtain  an  adult 
who  will  not  incorporate  her  own  ideas  into  the  interpreta- 
tion. It  is  imperative  that  the  nurse  understand  some  of 
the  language  with  which  she  is  dealing,  if  she  is  to  meet 
with  the  greatest  possible  success.     (Detroit,  Michigan.) 

Of  course  the  difficulty  in  using  an  interpreter  is  their 
tendency  to  put  their  owti  construction  on  the  sentence  to 
be  translated.     (Worcester,  Massachusetts.) 

An  exception  is  stated  as  follows: 

It  has  been  my  personal  experience  that  when  a  young 
couple  are  living  alone  they  are  usually  anxious  and  willing 
to  learn  from  us  and  the  man  makes  an  interested  and 
faithful  interpreter. 

When  such  an  interpreter  is  found,  the  nurse  can  do 
no  better  than  to  make  use  of  him. 

In  families  where  the  children  attend  American 
schools,  speaking  EngHsh  at  school,  and  the  mother 
tongue  at  home,  they  are  often  the  most  available 
translators.  In  so  far  as  the  child  is  relatively  free 
from  old-country  traditions  and  from  motives  of  self- 
interest,  he  can  truly  render  the  message  as  spoken. 

287 


IMMIGRANT  HEALTH  AND  COMMUNITY 

The  following  statement  comes  from  New  Haven, 
Connecticut : 

A  great  many  nurses  have  always  made  it  a  point,  when- 
ever possible,  to  use  a  child  interpreter,  for  by  so  doing  the 
child  was  also  learning  a  valuable  lesson.  Of  course  too 
young  a  child  would  not  be  used. 

Using  the  child  interpreter  also  has  its  difficulties,  as 
brought  out  by  the  following: 

Probably  the  chief  difficulty  is  in  having  children  in- 
terpret for  mothers  concerning  matters  which  they  do  not 
understand  and  should  better  not  know  of.  (Fitchburg, 
Massachusetts . ) 

We  find  that  many  times  if  what  the  mother  tells  the 
child  to  say  to  the  nurse  does  not  please  the  child  she  will 
not  tell  it.     (Providence,  Rhode  Island.) 

A  suggestion  of  the  happy  mean  comes  from  Spring- 
field, Massachusetts: 

We  consider  an  intelligent  chUd  of  fourteen  a  better  in- 
terpreter by  virtue  of  her  schooling  in  this  country  and 
because  she  will  give  a  more  accurate  interpretation  than 
an  adult  who  has  learned  our  language  in  a  general  way  and 
who  also  is  apt  to  add  his  own  interpretation  and  sug- 
gestions to  what  is  said. 

Great  care,  however,  must  be  taken  in  using  chil- 
dren as  interpreters,  lest  the  child  develop  an  undue 
sense  of  importance.  Too  often  the  child  who  learns 
English  and  "American  ways"  at  school,  comes  to 
look  down  upon  the  "old  people"  as  far  behind  the 
times.  A  fine  and  wholesome  family  life  may  thus  be 
broken  up  and  nothing  substituted  in  its  place. 

One  thing  obvious  from  the  answers  to  our  inquiries 
is  that  the  question  of  interpretation  has  been  taken 
too  casually  by  the  majority  of  visiting-nurse  asso- 


FIELD  WORK  WITH  THE  IMMIGRANT 

ciations  and  other  agencies,  those  who  spoke  of  it  in 
the  least  analytically  being  decidedly  the  exception. 

The  use  of  foreign-language  literature  is  quite  gen- 
eral among  tuberculosis  workers,  visiting-nurse  asso- 
ciations, social-service  departments,  and  other  health 
agencies.  State  departments  of  health,  because  of 
their  educational  and  advisory  functions,  are  notable 
among  agencies  which  have  developed  the  use  of 
foreign-language  literature  extensively.  The  baby- 
welfare  and  tuberculosis  campaigns,  pushed  by  many 
state  departments,  have  utilized  foreign-language  leaf- 
lets in  Pennsylvania,  New  York,  Massachusetts,  Lou- 
isiana, Maine,  and  doubtless  elsewhere.  The  recently 
developed  campaign  against  venereal  disease  has  led 
in  several  states  to  the  printing  of  advice  and  instruc- 
tion in  many  foreign  languages. 

The  New  York  State  Department  of  Health  used 
foreign-language  literature  to  reach  the  foreign  born 
in  connection  with  birth  registration.  Its  methods 
are  described  by  one  of  its  officers: 

Four  years  ago  (1914)  when  the  new  vital  statistics  law 
went  into  effect  posters  were  printed  in  several  different 
languages  calling  attention  to  the  law  in  regard  to  birth 
registration.  At  that  time  in  addition  to  the  posters  we 
had  exhibits  in  foreign  languages  and  also  lecturers  and 
nurses  who  could  talk  to  the  foreigners  in  their  own  lan- 
guage. We  also  had  the  co-operation  of  local  workers  who 
were  either  of  foreign  extraction  or  who  knew  the  language 
of  the  people  with  whom  they  came  in  contact. 

The  limitations  of  the  printed  word  are  serious,  however. 
From  New  Haven,  Connecticut,  comes  this  report : 

Our  nurses  feel  that  literature  must  be  very  brief  and  very 
much  to  the  point  or  it  will  not  be  read. 

289 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Others  report  that  a  pamphlet  printed  in  EngHsh, 
even  though  it  has  to  be  read  and  explained  to  the 
parents  by  the  children,  accomplishes  more  in  a  home. 
We  get  from  Buffalo  a  statement  typical  of  points  of 
view  in  other  cities : 

We  find  that  if  the  Italian  can  read  at  all  he  can  read 
English,  and  to  some  extent  the  same  is  true  of  the  Pole. 

The  strongest  statement  of  all  comes  from  Akron, 
Ohio: 

We  have  never  used  literature  printed  in  foreign  languages 
to  any  great  extent.  The  Americanization  movement 
rather  discourages  it  because  we  wish  the  foreign  people  to 
learn  our  language. 

It  is  fair  to  say  that  there  are  two  sides  to  this 
question,  or  perhaps  two  stages.  To  reach  the  recent 
immigrant  it  is  usually  necessary  to  use  his  own  lan- 
guage in  speech  and  print,  but  as  time  goes  on  he 
should  be  encouraged  and  expected  to  venture  into 
American  life  and  speech. 

Some  personal  knowledge  of  the  immigrant's  own 
tongue  is  of  inestimable  value  to  the  nurse,  even 
though  the  bulk  of  her  conversation  must  be  through 
an  interpreter.  To  the  immigrant  fearful  of  the  un- 
familiar and  the  incomprehensible,  what  a  ray  of  hope 
must  be  the  visit  of  a  nurse  who  speaks  his  familiar 
tongue,  even  if  only  a  few  words.  The  following  com- 
ment is  submitted  as  an  instance  of  the  importance  of 
language : 

We  are  fully  50  per  cent  French  Canadian  here  in  Man- 
chester, and  until  I  added  two  French-speaking  nurses  to 
our  staff  our  work  for  the  Metropolitan  Life  Insurance 
remained  at  a  standstill. 

290 


FIELD  WORK  WITH  THE  IMMIGRANT 

At  the  present  time  a  few  visiting-nurse  associations 
are  encouraging  their  nurses  to  take  definite  courses 
in  the  foreign  languages  which  are  chiefly  spoken  in 
their  districts.  Many  nurses  and  social  workers,  how- 
ever, have  not  time  for  extended  courses  in  which  the 
instruction  is  developed  along  literary  rather  than 
practical  lines.  The  end  to  be  achieved  is  the  require- 
ment, not  of  immediate  fluency  in  Italian,  Yiddish, 
or  Syrian,  but  of  enough  words  to  build  a  bridge  be- 
tween the  newcomer  and  the  American,  to  develop 
and  sustain  a  mutual  interest,  and  to  lay  the  founda- 
tion for  the  continual  growth  of  vocabulary  through 
the  nurses'  daily  work.  We  have  found  nurses  and 
social  workers  who  have  worked  for  years  among  one 
race  without  acquiring  any  of  the  language,  and  others 
who  have  learned  more  and  more  of  it  each  year. 
The  difference  was  that  one  set  of  people  were  given 
a  start,  while  the  others  never  were. 

Of  much  practical  assistance  are  phrase  books  giv- 
ing the  words  and  sentences  frequently  used  in  medi- 
cal and  health  work.  The  English-Italian  Phrase  Book 
for  Social  Workers^  by  Miss  Edith  Waller,  with  its 
special  supplement  for  the  use  of  physicians,  is  a  good 
example.  There  was  published  in  1916  ^  Handbook 
of  Phrases  in  Four  Languages  (Italian,  Bohemian,  Ger- 
man, and  English),  especially  for  the  use  of  district 
nurses.  This  was  issued  by  the  Visiting  Nurses'  As- 
sociation of  Cleveland,  Ohio,  under  the  auspices  of 
the  National  Organization  for  Public  Health  Nursing. 
In  1918  the  national  organization  itself  pubHshed  a 
smaller  handbook  of  phrases  in  Spanish  and  EngHsh. 
The  Visiting  Nurses'  Association  of  Topeka,  Kansas, 

prepared  a  brief  list  of  phrases  for  its  nurses,  "just  to 

291 


IMMIGRANT  HEALTH  AND  COMMUNITY 

give  them  a  start."  The  preparation  of  such  phrase 
books  can  be  carried  out  more  efficiently  by  national 
organizations  than  by  a  number  of  local  bodies.  There 
seems  every  reason  why  they  should  take  up  this 
matter. 

The  subject  matter  of  a  phrase  book  should  be 
suited  to  the  special  vocabulary  of  the  work  in  which 
it  is  to  be  used.  It  would  be  unwise  to  have  one  phrase 
book  prepared  for  the  use  of  either  teachers,  nurses, 
or  general  social  workers.  The  vocabulary  would  have 
to  be  so  large  that  the  book  would  be  much  less  useful 
than  would  three  separate  booklets.  The  ends  to  be 
sought  are  the  utmost  practicality  and  brevity.  Some 
of  the  published  phrase  books  have  failed  to  give  in- 
struction in  pronunciation — a  serious  defect. 

It  seems  a  pity  not  to  include  in  such  a  phrase  book 
something  about  the  backgrounds  and  characteristics 
of  the  people,  even  if  it  be  only  a  single  page.  This  is 
for  the  same  reason  that  a  conference  with  a  repre- 
sentative of  the  immigrant  group  is  the  best  introduc- 
tion to  a  study  of  the  group.  The  development  of 
interest  and  understanding  concerning  the  people  will 
lead  inevitably  to  some  mastery  of  the  language  if 
even  a  slight  start  is  made,  but  without  such  under- 
standing the  acquirement  of  the  language  can  be  little 
more  than  a  required  task. 

No  more  suggestive  and  practical  piece  of  work  of 
this  type  has  been  done  than  that  by  the  Rev.  Francis 
A.  Bimanski,  one  of  the  chaplains  of  Cook  County 
Hospital,  Chicago.  This  devoted  worker  among  the 
Polish  people  felt  keenly  their  isolation  and  loneliness 
in  the  great  hospital.  He  also  appreciated  the  diffi- 
culty experienced  by  the  visiting  staff,  the  internes, 

£92 


FIELD  WORK  WITH  THE  IMMIGRANT 

and  the  nurses  in  securing  the  necessary  medical  or 
social  information  from  patients  who  spoke  no  English. 
So  he  set  himself,  in  the  face  of  many  obstacles,  to 
remedy  this  defect.  He  made  a  beginning  by  taking 
some  simple  questions  and  answers  which  had  to  be 
frequently  asked.  In  order  to  ascertain  the  primary 
complaint  of  the  patient,  he  developed  the  phrase : 

"Pains.^"    Where.^"    "Show  with  fingers." 

Raising  the  money  himself,  he  had  a  little  slip 
printed  with  this  heading,  and  its  translation  into 
Polish  and  half  a  dozen  other  languages,  phonetically 
written  so  that  anyone  could  come  somewhere  near 
pronouncing  the  words,  near  enough,  at  least, 
for  the  patient  to  understand.  Any  person  who  has 
tried  to  elicit  the  symptoms  of  a  patient  who  can 
speak  no  English  will  appreciate  the  practical  value 
of  this. 

Carrying  on  the  same  idea,  he  worked  out  a  series 
of  other  practical  questions,  translated  and  printed 
phonetically  in  several  languages.  Some  of  the  prints 
were  made  on  large  sheets,  which  could  be  posted  in 
a  ward  or  a  clinic.  He  also  prepared  pocket-size 
leaflets  of  from  four  to  sixteen  pages,  and  made  an 
endeavor  to  teach  nurses  and  internes  systematically. 

These  leaflets  might  be  improved  in  certain  details, 
but  examination  of  them  will  be  very  suggestive 
to  anyone  who  seeks  to  improve  existing  phrase 
books  or  develop  still  better  ones.  In  every  one  of 
his  leaflets,  Father  Bimanski  included  something  about 
the  people  or  peoples  concerned.  His  practical  expe- 
rience had  led  him  to  the  same  conviction  of  which 
our  study  is  so  full,  that  knowledge  of  a  people,  and 
respect  and  sympathy  for  them,  are  the  foundation 

20  293 


IMMIGRANT  HEALTH  AND  COMMUNITY 

for  happier  work  with  them,  and  for  better  results  in 
professional  service. 

In  learning  the  language  of  the  immigrants,  how- 
ever, the  aim  must  not  be  lost  sight  of.  This  is  that 
English  be  the  ultimate  medium  of  communication. 
The  American  worker  should  use  the  foreign  tongues 
only  to  bridge  the  first  strangeness  with  a  friendly- 
familiar  word.  A  wise  caution  is  expressed  in  the 
following: 

The  nurse  who  speaks  the  language  fluently  has  a  dis- 
tinct advantage  over  the  other  nurses  if  under  the  pressure 
of  work  that  is  bound  to  come  to  every  public-health  nurse 
she  does  not  lose  sight  of  the  eventual  naturalization  of  the 
patients.  For  the  fusion  of  these  people  with  the  native 
born,  as  well  as  teaching  right  living,  is  our  aim.  (Detroit, 
Michigan.) 

KNOWLEDGE   OF  BACKGROUNDS 

More  important  than  reaching  the  immigrant  in  his 
own  language  is  reaching  him  sympathetically.  This 
can  be  done  best  by  showing  an  interest  in  the  land  of 
his  birth.  Miss  Lillian  Wald  says  of  her  early  days  on 
the  East  Side,  "I  could  not  speak  their  languages,  but 
I  could  smile  in  fifty-seven  tongues.'*  This  point  was 
brought  out  by  many  answers  to  our  inquiries: 

The  right  kind  of  nurse  can  do  very  effective  work  even 
though  she  cannot  speak  or  understand  the  foreign  lan- 
guages. Our  greatest  success  has  been  with  a  nurse  not 
speaking  Italian,  but  picking  up  words  and  expressions, 
getting  the  background  of  the  patients,  their  former  en- 
vironment, their  holidays,  and  great  men.  (Shenandoah, 
Pennsylvania.) 

A  hospital  social-service  department  in  St.    Louis 

states : 

294 


FIELD  WORK  WITH  THE  IMMIGRANT 

It  is  advisable  that  my  social  workers  have  a  most 
thorough  knowledge  of  the  backgrounds  of  the  foreign  bom; 
necessary  that  they  at  least  have  a  course  in  race  history 
and  race  problems  either  in  an  accredited  college  or  in  a 
school  for  social  workers. 

The  head  of  a  social-service  department  in  Philadel- 
phia testified: 

The  well-equipped  worker  ought  to  have  a  knowledge  of 
the  conditions  under  which  the  foreign  born  lived  at  home, 
their  employment,  habits,  recreation,  education,  religion, 
and  traditions;  why  they  came  to  this  country;  to  what 
degree  they  have  been  exploited  industrially;  in  what  way 
their  present  environment  differs  from  the  old  one,  and  the 
disadvantages  and  advantages  of  their  present  environ- 
ment; a  knowledge,  too,  of  the  historical  background;  the 
part  the  nation  has  played  in  the  development  of  art, 
science,  and  religion.  With  this  knowledge  there  ought  to 
be  a  strong  feeling  for  the  whole  human  race  as  one  family. 
We  must  recognize  *'The  broad  sameness  of  the  human  lot 
which  never  alters  in  the  main  headings  of  its  history — 
hunger  and  labor,  seed  time  and  harvest,  love  and  death.'* 

Much  should  be  added  to  the  classroom  instruction 
in  immigrant  backgrounds  and  characteristics.  Lec- 
tures alone,  without  personal  contact  with  immigrant 
families,  are  almost  valueless.  All  good  schools  give 
the  student,  whether  she  be  the  prospective  nurse, 
social  worker,  or  dietitian,  a  certain  amount  of  prac- 
tical experience  under  supervision,  and  the  best  schools 
devote  to  this  a  considerable  proportion  of  the  stu- 
dent's time  during  the  latter  part  of  her  course.  It 
is  not  difficult  to  include  contact  with  immigrants  of 
difiPerent  groups  in  this  experience  and  to  have  these 
contacts  interpreted  by  the  teacher  or  by  special  per- 
sons familiar  with  the  race  groups. 

295 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Medical  and  health  work  cannot,  however,  wait 
upon  the  training  of  new  workers.  The  thousands 
who  are  already  in  the  field,  and  who  are  working 
with  immigrant  groups,  must  get  their  knowledge  of 
immigrant  backgrounds  without  formal  courses. 

To  a  certain  extent  they  can  do  this  through  litera- 
ture. The  pamphlets  issued  by  the  Americanization 
Committee  of  Cleveland  exemplify  a  much-needed 
type  of  publication.  Each  booklet  is  devoted  to  a 
particular  race  group,  prominent  in  the  city:  "The 
Slovaks  of  Cleveland,"  "The  Hungarians  of  Cleve- 
land," "The  Poles  of  Cleveland."  The  booklets  are 
brief,  some  sixteen  to  twenty-four  pages,  well  illus- 
trated with  photographs,  and  contain  material  of 
local  and  practical  interest  as  well  as  a  historical 
account  of  the  race  in  question. 

The  publication  of  such  booklets  by  Americaniza- 
tion authorities  in  other  cities  is  much  to  be  desired. 
A  national  authority  or  committee  might  prepare  in- 
terestingly written  accounts  of  different  race  groups, 
and  in  co-operation  with  local  and  state  authorities 
have  these  suitably  modified  in  different  states,  cities, 
or  sections  of  the  country.  Items  of  local  as  well  as 
of  general  interest  regarding  an  immigrant  group  are 
of  so  much  value  in  these  booklets  that  it  seems  ques- 
tionable whether  they  should  be  uniform  throughout 
the  country. 

There  is  a  place  for  even  briefer  leaflets  of  the  same 
character.  Small  folders  designed  especially  for  per- 
sons concerned  with  educational,  social,  or  health 
work  for  the  foreign  born  might  well  be  prepared 
by  such  national  organizations  as  the  American  Pub- 
lic Health  Association,   the    National    Tuberculosis 

296 


FIELD  WORK  WITH  THE  IMMIGRANT 

Association,     or     the     American     Social     Hygiene 
Association. 

These  leaflets  should  include  a  brief  account  of  the 
people's  European  history,  tradition,  characteristics, 
their  numbers,  location,  and  activities  within  the 
United  States,  and  might  be  combined,  in  some  cases, 
with  the  phrase  books  designed  to  open  the  way  in 
using  the  immigrant's  language.  Items  of  interest  to 
a  particular  state  or  city  could  be  added  to  this  mate- 
rial by  the  local  authorities.  To  instruct  visiting 
nurses  or  hospital  social  workers  by  the  use  of  leaflets 
alone  would  not  take  us  very  far,  but  it  would  be  a 
move  in  the  right  direction. 

A  more  important  step  would  be  for  nursing  and 
social-service  staffs  to  hold  a  few  conferences  each 
year  with  leaders  of  different  inamigrant  races,  or  per- 
sons who  are  familiar  at  first  hand  with  these  races. 
After  all,  nothing  arouses  more  interest  in  an  immi- 
grant group  than  hearing  it  described  by  a  man  or 
woman  of  the  right  type  who  is  close  to  it.    Attendance 
at  a  single  meeting  of  this  kind  has  been  known  to 
change  a  nurse's  or  social  worker's  whole  attitude 
toward  a  group  of  immigrants.    The  time  and  effort 
required  to  arrange  such  conferences  for  the  staff  of 
a  visiting  nurses'  association,  a  social-service  depart- 
ment, or  a  tuberculosis  committee  would  be  small  in 
proportion  to  the  great  benefits  that  would  be  derived. 
It  may  be  pointed  out  also  that  these  benefits  would 
be   mutual,   increasing  the  co-operativeness   of   the 
immigrants  as  well  as  of  the  workers. 

Once  the  right  start  is  made,  the  rest  largely  takes 
care  of  itself  through  the  contacts  of  the  daily  work. 
These  contacts  mean  little  or  nothing  without  a  suffi- 

297 


IMMIGRANT  HEALTH  AND  COMMUNITY 

cient  basis  of  interest  and  knowledge  for  them  to  be 
emotionally  warm  and  intellectually  understood;  but 
once  the  field  agent's  interest  is  aroused,  it  is  surpris- 
ing how  little  information  about  the  Poles,  the  Jews, 
the  Italians,  or  the  Lithuanians  she  needs  as  a  basis 
on  which  to  build  further  knowledge  automatically. 

Too  much  care  cannot  be  taken  that  the  attitude 
toward  the  immigrant  is  not  based  on  the  premise 
that  we  are  right  and  he  is  wrong.  A  few  associations 
express  a  wish,  and  many  show  a  need,  for  more  sym- 
pathetic understanding  of  the  foreign-born  patients. 
Witness  such  complaints  as,  "They  don't  seem  to 
know  anything  about  American  customs  or  about 
tuberculosis." 

When  nurses  complain  that  immigrants  have  too 
many  children,  that  they  seem  to  cling  to  their  own 
customs,  it  shows  a  kind  of  provincialism  and  igno- 
rance even  worse  than  that  of  their  patients.  Espe- 
cially refreshing,  therefore,  were  the  replies  from  two 
organizations  who  admitted  that  perhaps  the  diffi- 
culties were  due  to  lack  of  knowledge  and  under- 
standing on  our  part,  an  attitude  of  mind  which  could 
profitably  be  encouraged  without  any  sacrifice  of 
American  standards.  One  executive  recognizes  this 
as  at  least  one  of  the  causes  for  failure  in  Americaniza- 
tion work.     He  says : 

I  think  that  your  committee  might  do  an  immediately 
needed  piece  of  work  for  public-health  nurses  if  it  would 
compile  a  list  of  books  and  magazine  articles  touching  upon 
the  problems  of  our  foreign  born  by  racial,  occupational 
groups  or  any  other  way.  If  this  list  can  be  made  of  books 
which  should  be  procurable  either  from  a  public  library 
or  a  bookseller  it  would  be  all  the  more  valuable.  Doubt- 
less there  are  such  lists,  but  most  of  us  don't  know  of  them. 

298 


FIELD  WORK  WITH  THE  IMMIGRANT 

This  is  a  need  less  obvious,  but  more  fundamental, 
than  that  of  phrase  books.  Such  knowledge  of  immi- 
grant backgrounds  is  needed  by  the  public-health 
nurse,  the  social  worker,  and,  in  fact,  by  everyone  who 
has  to  deal  with  his  foreign-born  neighbor. 

LOCALIZATION   OF   HEALTH   WORK 

Another  suggestion  is  that  we  take  the  trouble  to  go 
to  the  foreign  born  with  what  we  have  to  give,  be  it 
a  baby  clinic,  a  housekeeping  center,  or  an  English 
class.  By  locating  it  in  his  part  of  town  we  avoid  the 
necessity  of  drawing  him  away  from  his  familiar 
streets  and  buildings.  One  baby  clinic  in  a  Texas 
city  trebled  the  enrollment  of  Mexican  babies  when 
it  moved  just  a  few  blocks  into  the  Mexican  district. 
Another  association  reached  the  foreign  children  by 
sending  a  nurse  daily  to  make  inspection  and  give 
lessons  in  hygiene  at  a  Polish  parochial  school. 

The  mother  in  her  home,  seldom,  if  ever,  getting 
out  to  gatherings  of  any  sort,  is  the  hardest  member 
of  the  immigrant  group  to  reach,  and  often  the  slowest 
to  give  up  her  racial  habits;  yet  in  her  position  as 
homekeeper  she  has  most  to  do  with  the  health  of 
her  family.  Taking  our  health  work  into  her  neigh- 
borhood is  the  surest  way  to  get  acquainted  with  her. 
If  her  headquarters  are  near  by,  the  nurse  makes  more 
friendly  visits,  calling  often  to  foster  familiarity  and 
affection. 

Above  all,  our  most  hopeful  approach  is  through 

the  baby  and  the  growing  children,  and  these  can  be 

more  easily  reached  by  a  neighborhood  unit.    Many 

replies  indicate  that  it  is  considered  practically  im- 

299 


IMMIGRANT  HEALTH  AND  COMMUNITY 

possible  to  enlist  the  attention  of  mothers  except 
through  service  offered  to  their  babies  and  younger 
children : 

A  great  many  of  the  habits  of  the  immigrant  we  have 
been  able  to  change  after  getting  the  mother  interested  in 
our  welfare  association.  I  consider  the  infant-welfare 
station  to  be  one  of  the  biggest  factors  in  Americanizing 
the  foreign  mothers  that  we  can  possibly  organize.  (Buf- 
falo, New  York.) 

Others  mention  the  Little  Mothers'  clubs,  which  teach 
the  younger  girls  in  the  schools,  as  the  best  approach 
to  the  parents : 

Teaching  *' Little  Mothers'  Clubs"  seems  to  clear  the 
way  for  Infant  Welfare  work,  and  we  often  find  the  children 
have  ordered  the  mother  to  give  the  baby  only  boiled  water 
if  ailing  and  while  waiting  for  the  nurse  to  come.  (Man- 
chester, New  Hampshire.) 

Care  must  be  taken  to  see  that  the  children  do  not 
scorn  their  parents'  habits,  but  recognize  the  good 
features  in  them.  The  public  school,  through  co- 
operation between  the  school  nurse  and  the  teacher 
and  through  parent-teacher's  meetings,  can  be  a  pow- 
erful factor  in  determining  this  attitude,  and  at  the 
same  time  appeal  to  mother  love,  the  strongest  motive 
in  the  world,  to  effect  changes  in  the  habits  of 
generations. 

In  local  health  work  it  is  often  possible  to  reach  a 

foreign-born  group  through  its  own  leaders.     The 

co-operation  of  lodges,  labor  unions,  and  religious 

bodies  of  the  foreign  born  has  been  sought  by  a  small 

number  of  tuberculosis  associations,  twelve  reporting 

definitely  upon  such  endeavors.    The  co-operation  of 

the  priest  is  not  infrequently  referred  to.     In  the 

300 


FIELD  WORK  WITH  THE  IMMIGRANT 

somewhat  slow  and  difficult  task  of  securing  the  co- 
operation of  immigrants  or  of  their  organizations,  the 
primary  need  for  democratic  and  sympathetic  ap- 
proach has  often  not  been  recognized.  A  notable 
exception  indicates  the  right  path. 

In  1910  the  Committee  on  the  Prevention  of  Tuber- 
culosis of  the  Charity  Organization  Society  of  New 
York,  under  the  direction  of  Dr.  LawTcnce  Veiller,^ 
organized  a  special  Italian  committee.  One  of  its 
first  activities  "was  to  get  up  a  very  attractive  colored 
poster  containing  a  picture  of  Venice  from  a  famous 
painting,  in  very  attractive  colors,  and  then  printing 
along  on  the  side  of  the  picture  advice  about  tuber- 
culosis, with  reference  to  the  nearest  tuberculosis  clinic 
for  that  district.'*  This  poster  was  also  printed  in 
reduced  size,  and  distributed  from  house  to  house 
through  the  Italian  tenement  districts  on  the  lower 
East  Side  of  Manhattan. 

Later  [says  Doctor  Veillerl  we  transferred  our  activities 
to  the  newer  Italian  quarter  on  the  upper  East  Side  in  the 
neighborhood  of  Thomas  Jefferson  Park,  around  114th 
Street,  after  having  first  made  a  study  of  the  need  of  a 
tuberculosis  clinic  for  the  Italians  in  that  section.  Having 
through  that  study  developed  this  need,  we  then  got  the 
Health  Department  to  establish  a  new  clinic  in  that  dis- 
trict and  after  that  we  then  proceeded  to  build  up  business 
for  the  clinic  by  having  our  Italian  visitor  go  from  house  to 
house  and  flat  to  flat  with  the  small  Venetian  poster  and 
on  it  a  reference  to  go  to  the  clinic  in  that  district.  Also, 
we  gave  them  a  little  card  of  reference  to  the  clinic.  The 
result  was  that  we  in  a  very  short  time  built  up  a  big 
business  for  the  clinic.  It  was  a  very  practical  and  effective 
piece  of  social  co-operation. 


^  The  citations  are  from  a  personal  letter  from  Doctor  Veiller. 

301 


IMMIGRANT  HEALTH  AND  COMMUNITY 

This  Italian  committee  continued  for  several  years. 
After  two  or  three  years,  the  first  interest  having  worn 
off,  it  became  difficult  to  keep  up  the  interest  of  the 
members  of  the  committee,  yet  it  was  felt  that  the 
committee  had  by  that  time  accomplished  its  purpose. 

Doctor  Veiller  says,  "It  more  than  justified  our 
expectations  and  more  than  warranted  the  expendi- 
ture we  put  into  it." 

SUMMARY 

The  material  received  from  many  health  workers, 
visiting  nurses,  infant-welfare  workers,  tuberculosis 
agencies,  and  social-service  departments,  regarding 
methods  of  field  work  with  the  immigrant,  may  be 
summed  up  in  several  conclusions.  The  chief  problem 
peculiar  to  work  with  immigrants  is  that  of  winning 
their  confidence  and  reaching  their  understanding 
over  the  barriers  of  mutual  unintelligibility  in  lan- 
guage, habits  of  life,  and  former  experience. 

1.  The  first  necessity  of  the  field  worker  is  to  find 
a  medium  of  communication  with  the  foreign  born. 
The  majority  will  have  to  depend  upon  interpreters. 
Since  the  employment  of  trained,  paid,  full-time  in- 
terpreters is  rarely  practicable,  some  plan  for  securing 
them  when  needed  must  be  developed.  The  chief 
point  is  that  securing  interpreters  must  be  systematic, 
not  haphazard.  In  field  work,  calling  in  or  taking 
along  one  of  a  certain  number  of  regular  local  inter- 
preters is  much  better  than  calling  in  a  chance  neigh- 
bor or  child.  Valuable  means  exist  here  of  building 
up  organized  co-operation  with  and  among  the  foreign 
born.    In  so  far  as  the  field  agents  are  equipped  with 

enough  knowledge  of  the  backgrounds  and  charac- 

302 


FIELD  WORK  WITH  THE  IMMIGRANT 

teristics  of  the  immigrants  to  understand  them  in 
general,  and  with  enough  knowledge  of  the  language 
to  get  the  main  points  of  the  situation,  interpretation 
will  almost  take  care  of  itself. 

2.  Kiiowledge  of  the  immigrant's  language  is  a 
great  help.  It  enables  the  health  worker  to  use  her 
interpreter  intelligently;  it  also  creates  a  feeling  of 
confidence  and  appreciation  on  the  part  of  the  patient 
and  of  sympathy  and  readiness  of  approach  on  the 
part  of  the  worker. 

3.  Experience  in  using  foreign-language  literature 
estabhshes  two  facts: 

a.  Where  literature  of  any  kind  is  to  be  given 
those  not  speaking  English,  it  should  be  in 
their  mother  tongue. 

h.  Literature  is  comparatively  ineffective  ex- 
cept as  a  supplement  to  the  spoken  word. 
T\Tien  so  used,  and  when  followed  up  by  a 
personal  conference  with  the  professional 
worker,  it  helps  to  drive  things  home,  to 
serve  as  a  reminder,  and  to  spread  a  little 
more  widely  the  message  given  to  the  in- 
dividual patient. 

It  is  important  that  the  persons  preparing  such  litera- 
ture be  sufficiently  informed  about  the  subject  matter 
and  also  have  enough  facility  in  the  foreign  language 
to  present  the  ideas  simply  and  interestingly.  Such 
highly  skilled  persons  are  often  beyond  the  command 
of  a  local  organization,  and  this  is  one  good  reason 
why  much  of  the  foreign-language  literature  giving 
instruction  in  hygiene  and  in  the  care  of  various  dis- 
eases should  be  prepared  by  national  or  state  authori- 
ses 


IMMIGRANT  HEALTH  AND  COMMUNITY 

ties  who  could  make  it  available  to  an  indefinite  num- 
ber of  local  agencies. 

4.  The  children,  because  of  their  superior  knowledge 
of  English  and  of  American  customs,  sometimes  offer 
the  readiest  means  of  access  to  immigrant  parents. 
Great  caution,  however,  must  be  observed  in  utilizing 
children  "to  teach  their  parents,"  lest  the  disintegra- 
tion of  family  life  be  encouraged. 

5.  Localization  of  field  work,  restricting  one  set  of 
workers  to  a  compact  area  with  headquarters  in  the 
district,  fosters  familiarity  and  subsequent  confidence. 

6.  To  secure  the  co-operation  of  the  foreign  born 
themselves  is  one  of  the  most  important  and  difficult 
tasks  confronting  field  workers. 

7.  The  primary  requisite  for  success  in  field  work 
with  the  foreign  born,  the  point  upon  which  all  other 
measures  depend,  is  knowledge  and  understanding  of 
the  people,  their  backgrounds  and  characteristics. 


XIV 

THE   HOSPITAL 

The  hospital  is  an  institution  where  patients  are  re- 
ceived whose  illness  requires  that  they  remain  in  bed 
and  receive  more  constant  care  and  supervision  than 
is  possible  in  their  homes.  For  the  purpose  of  this 
study  hospitals  may  be  divided  into  two  kinds : 

1.  The  public-service  hospital  is  a  hospital,  whether 
supported  by  public  or  private  funds,  which  takes  at 
least  some  patients  as  a  service  to  the  community 
and  not  merely  in  return  for  payment. 

2.  The  proprietary  hospital  is  run  as  a  business 
enterprise.  The  term  "private"  should  not  be  ap- 
plied to  hospitals  of  this  second  class  because  it  is 
ambiguous,  being  used  sometimes  to  mean  supported 
by  private  as  distinguished  from  public  funds,  and 
sometimes  to  mean  maintained  for  private  profit. 

Hospitals  are  unevenly  distributed  throughout  the 
United  States.  A  disproportionate  number  are  found 
in  the  larger  cities  and  in  the  older  communities  of 
the  East.  The  majority  of  these  hospitals  are  of  small 
size.  There  are  3,187  hospitals  listed  in  the  American 
Medical  Directory  of  1918  which,  on  the  basis  of  in- 
formation therein  contained,  have  been  tentatively 
classified  as  general  hospitals  of  the  first,  or  public- 
service,  class.  One  thousand  two  hundred  and  thirty- 
nine  of  these,  or  39  per  cent,  had  25  beds  or  fewer. 

305 


IMMIGRANT  HEALTH  AND  COMMUNITY 

There  were  almost  exactly  the  same  number  (1,246) 
with  from  26  to  99  beds.  Only  702  hospitals  had  100 
beds  or  more.  The  number  of  private  proprietary 
hospitals  is  much  larger,  but  the  great  bulk  are  small, 
having  25  beds  or  less. 

In  discussing,  the  relation  of  the  hospital  to  the 
medical  care  of  the  immigrant  we  are  practically 
limited  to  the  public-service  group,  chiefly  to  the  in- 
stitutions of  100  beds  or  more.  The  most  highly  de- 
veloped examples  of  hospital  service  are  found  in  the 
large  hospitals,  particularly  in  those  which  are  affili- 
ated with  medical  schools  and  are  university  or  teach- 
ing hospitals. 

In  view  of  the  fact  that  a  large  number  of  northern 
Europeans  have  settled  in  the  growing  industrial  com- 
munities of  middle  size  and  in  the  small  towns  and 
rural  districts,  it  is  significant  that  the  66  medical 
schools  of  the  country  are  nearly  all  located  in  large 
cities,  that  the  number  of  medical  schools  is  likely  to 
diminish  rather  than  to  increase,  and  that  hospitals 
established  and  maintained  in  intimate  co-operation 
with  these  schools  can  reach  only  a  very  small  fraction 
of  the  population  in  each  state.  These  facts  are 
fundamental  to  a  consideration  of  hospital  service 
for  the  immigrant. 

IMMIGRANT   ATTITUDES 

The  service  that  hospitals  can  render  the  immigrant 

is  in  part  dependent  upon  his  attitude  toward  the 

hospital.    This  is  brought  out  by  interviews  with  the 

foreign  born,  both  doctors  and  laymen. 

A  Polish  doctor  says: 

306 


THE  HOSPITAL 

Poles  are  decidedly  opposed  to  going  to  the  hospital 
under  any  circumstances  or  to  allowing  their  children  to 
be  taken.  To  go  to  the  hospital  is  to  die,  they  think, 
because  in  their  experience  it  has  always  meant  the  last 
resort.  Aside  from  this,  they  lack  confidence  in  hospitals. 
The  strangest  stories  gain  currency  among  them  about 
practices  in  the  hospitals  and  the  doctors  can't  reassure 
them.  They  actdally  believe  that  patients  die  of  neglect 
or  are  killed  by  "black  medicine." 

A  Russian  doctor  says: 

Russians  are  afraid  to  go  to  the  hospital;  they  have  known 
little  or  nothing  of  them  in  the  old  country,  and  the  ex- 
periences of  people  of  their  own  nationality  in  the  hospitals 
of  this  country  have  not  served  to  give  them  any  faith  in 
them,  for  they  do  not  understand  the  treatments.  Ex- 
aggerated stories  easily  gain  currency.  The  lack  of  the 
language  makes  them  feel  strange  and  helpless. 

An  Italian  doctor  says: 

The  masses  of  the  Italian  people  have  a  deep-seated 
prejudice  against  hospitals.  It  would  be  difficult  to  find 
the  cause  of  it.  I  cannot  understand  it;  it  is  like  many 
of  the  superstitions  of  ignorant  people.  They  say  people 
are  abused,  or  neglected,  or  killed  in  hospitals.  The 
younger  generation  is  of  course  getting  away  from  such 
notions,  but  still  I  have  to  deal  with  many  cases  at  home 
when  I  know  recovery  would  be  much  more  certain  in  a 
hospital. 

The  immigrant's  attitude  toward  the  hospital  of 
course  depends  partly  on  his  background  and  partly 
on  his  personality  and  immediate  circumstances.  If 
he  has  come  from  a  district  abroad  in  which  hospitals 
are  distant  places  to  which  only  desperately  ill  people 
are  sent,  naturally  he  comes  to  America  with  a  dif- 
ferent notion  than  if  he  had  been  brought  up  in  a 

307 


IMMIGRANT  HEALTH  AND  COMMUNITY 

large  city  well  provided  with  hospitals.  Once  located 
in  an  American  city,  the  immigrant  and  his  family 
may  be  in  continuous  good  health,  but  they  are  almost 
certain  to  hear  about  a  neighbor  or  friend  who  has 
been  taken  to  this  or  that  hospital  because  of  accident 
or  illness. 

Those  who  visit  a  patient  report  their  impressions. 
The  patient  himself  returns  and  does  likewise.  Should 
the  patient  die  at  the  hospital,  a  feeling  of  fear  or  re- 
pugnance may  be  strongly  confirmed  among  his  ac- 
quaintances. Most  hospitals  give  even  the  sophisti- 
cated visitor  a  sense  of  being  surrounded  by  very 
busy,  presumably  very  efficient,  doctors,  nurses,  and 
employees,  who  are  passing  rapidly  from  one  duty  to 
another  and  have  little  time  for  him.  When  to  the 
intrinsically  depressing  features  of  a  hospital  are 
added  unfamiliarity  with  the  language  spoken  there, 
and  a  sense  of  isolation  and  helplessness,  the  immi- 
grant may  be  pardoned  for  sharing  what  an  American 
visitor  to  many  hospitals  described  as  "a  sinking  feel- 
ing in  the  chest."  It  is  easy  to  understand  how  the 
impressions  of  the  individual  immigrants  quoted  be- 
low were  acquired.    A  Lettish  immigrant  reports: 

Does  not  trust  hospitals  or  dispensaries,  especially  city 
hospitals,  which  many  of  the  men  from  the  factory  had  been 
sent  to  when  different  accidents  happened.  One  or  two 
of  them  had  died  and  the  family  and  neighbors  look  upon 
all  hospitals  as  a  place  where  one  goes  to  die. 

From  two  Lithuanians  come  the  following  testimonies : 

All  hospitals  are  the  same  to  Mr.  M.  "When  men  are 
hurt  in  the  factory  they  are  sent  there,  and  if  the  young 
doctors  do  not  practice  on  them  they  live,  but  otherwise 

308 


THE  HOSPITAL 

they  die.'*  Mr.  M.  had  no  other  occasion  to  use  doctors. 
When  he  had  a  cold  and  sore  throat  he  told  the  druggist 
what  the  trouble  was  and  he  gave  him  some  medicine. 
*'0f  course  the  druggist  knows  what  is  good  for  you." 

Had  to  go  to  hospital  for  spinal  trouble.  Did  not  like 
the  hospital,  as  they  were  not  kind  to  her.  They  spoke  in  a 
foreign  tongue  which  she  could  not  comprehend. 

The  attitude  toward  hospitals  revealed  in  one  hun- 
dred and  fifty  interviews  with  doctors,  and  about  an 
equal  number  with  individual  immigrants,  could  be 
summarized  in  the  following  opinions: 

A  strange  place. 

A  place  in  which  I  cannot  understand  what  people 
say,  nor  be  understood. 

A  place  where  doctors  practice  on  you,  especially 
young  doctors. 

A  place  where  people  die. 

A  place  where  I  cannot  get  the  food  I  like  or  am 
used  to. 

A  place  where  either  I  have  to  take  charity  or  pay 
more  than  I  can  afford. 

These  items  are  listed  in  about  their  order  of  fre- 
quency or  importance,  so  far  as  can  be  judged  from 
the  material  at  hand.  Obviously  the  degree  of  strange- 
ness varies  with  the  individual  and  his  previous  ex- 
perience with  hospitals.  An  immigrant  who  speaks 
even  a  little  English  is  far  less  isolated  and  unhappy 
in  a  hospital  than  one  who  may  be  shut  off  for  weeks 
with  people  who  cannot  speak  a  word  of  the  only 
tongue  he  knows.  The  education  or  intelligence  of 
the  patient,  as  well  as  his  previous  experience  in  medi- 
cal institutions,  will  determine  whether  he  believes 
the  false  stories  about  doctors  **  practicing  on  patients," 
21  309 


I- 


IMMIGRANT  HEALTH  AND  COMMUNITY 

and  whether  he  fears  hospitals  for  the  reason  that  the 
sailorman  in  the  story  feared  beds — because  most 
people  die  there. 

Dislike  of  accepting  charity  is  a  psychological  bar- 
rier between  the  immigrant  and  the  hospital,  although 
the  feeling  is  not  so  strong  against  medical  charity  as 
against  material  relief.  On  the  other  hand,  most  hos- 
pitals have  only  a  few  low-priced  beds,  and  the  so- 
called  ward  rate  seems,  and  often  is,  a  considerable 
sum  to  the  wage  earner.  The  hospitals  supported  by 
public  funds,  and  the  large  endowed  hospitals,  present 
no  financial  obstacles,  but  most  of  our  middle-sized 
and  small  communities  have  as  yet  an  extremely 
limited  number  of  free  or  low-priced  beds. 

Not  even  the  educated  layman  can  be  expected  to 
appraise  the  professional  work  of  hospitals  according 
to  standards  of  medical  efficiency.  Their  opinion  is 
necessarily  based  upon  their  personal  judgment  of  the 
thoroughness  and  rapidity  of  their  cure,  and  the  com- 
fort and  pleasantness  of  their  stay  in  the  institution. 
To  what  extent  can  the  American  hospital  create  a 
satisfactory  human  relationship  with  the  foreign-born 
patient  .f^  So  far  there  is  little  evidence  that  large  hos- 
pitals have  adapted  themselves  to  the  needs  of  race 
groups.  The  objections  to  hospitals  urged  by  individ- 
ual doctors  and  immigrants  throw  light  on  some  of 
the  difficulties. 

In  so  far  as  these  are  based  on  lack  of  confidence, 
the  only  remedy  is  to  change  the  immigrant's  attitude. 
This  is  done  by  the  slow  process  of  gaining  his  confi- 
dence and  ousting  superstitions  and  rumors  by  dem- 
onstrating the  benefits  of  prompt  and  adequate  medi- 
cal care.     But  the  difficulties  that  arise  from  such 

310 


THE  HOSPITAL 

causes  as  dislike  of  strange  food  and  lack  of  a  means 
of  communication  can  be  met  only  by  special  changes 
in  hospital  procedure  and  administration.  These  all 
too  often  are  found  to  be  entirely  lacking. 

DIETS    FOR   THE   FOREIGN   BORN 

All  hospitals  of  any  size  have  dietitians.  In  some 
hospitals  the  dietitian  has  direct  responsibility  for  the 
menus  of  private  or  semiprivate  cases  only,  while  the 
menus  for  ward  cases  are  made  up  by  some  subordinate 
or  cook.  Yet  even  in  such  hospitals  the  dietitians* 
influence  over  the  general  menu  is  very  considerable. 
In  any  case,  the  dietitian  is  the  trained  professional 
person  through  w^hom  the  hospital  must  work  in  alter- 
ing or  advancing  its  dietary  standards  and  methods. 
Twenty-six  representative  dietitians  whose  names 
were  supplied  by  an  official  of  the  American  Dietetic 
Association  were  asked  whether  they  had  worked  out 
and  put  into  practice  any  special  diets  for  foreign-born 
patients  in  their  hospitals;  whether  they  felt  that 
foreign-born  patients  presented  a  dietary  problem, 
and  whether  they  thought  it  desirable  and  practicable 
to  adapt  their  dietary  to  such  patients. 

Of  the  thirteen  who  replied,  nine  were  doing  nothing 
in  this  matter.  One  said  that  they  had  very  few 
foreign-born  patients  in  their  hospital  and  therefore 
no  problem  of  this  kind.  Two  had  previously  main- 
tained a  kosher  kitchen  for  Jewish  patients,  but  had 
discontinued  this.  One  dietitian  said  they  were  serv- 
ing fish  on  Fridays  for  Catholic  patients,  the  majority 
of  whom  were  foreign  born.     Many  hospitals  do  this 

without  regard  to  nationality  of  patients.    A  few  die- 

311 


IMMIGRANT  HEALTH  AND  COMMUNITY 

titians  realized  the  importance  of  the  problem.    One 
of  these  said: 

The  only  information  which  I  can  give  you  in  regard  to 
special  diets  for  foreign-born  patients  is  that  we  consider 
each  patient  as  an  individual  and,  as  far  as  is  practicable, 
arrange  the  diet  in  accordance  with  his  previous  food  habits. 
We  have  here  Italian  patients,  Irish  patients,  and  patients 
with  Jewish  religious  preferences.  The  student  dietitians 
are  instructed  in  the  dietary  habits  of  these  people,  and  they 
regulate  their  menus  accordingly.  For  the  patients  on 
regular  house  diet  we  make  no  distinction  of  nationality 
or  religion.  As  we  have  only  about  two  hundred  and 
fifty  patients  scattered  over  some  fifteen  wards,  we  have 
not  found  it  practicable  to  differentiate  in  the  food.  I 
think  the  idea  is  very  splendid  if  the  percentage  of  patients 
is  high  enough  to  warrant  considering  national  food  cus- 
toms, as  the  psychological  effect  of  food  upon  the  patient 
has  much  to  do  with  his  recovery,  and  it  impresses  me  that 
hospitals  should  take  this  into  consideration.  If  I  were  to 
handle  the  food  proposition  for  a  hospital  having  Italian 
patients  I  should  have  an  Italian  cook. 

The  president  of  the  American  Dietetic  Association, 
referring  to  this^  inquiry,  said  in  a  letter : 

We  have  many  foreign-born  patients  in  our  various 
hospitals  who  do  not  react  favorably  to  treatment,  es- 
pecially dietotherapy,  because  they  are  unwilling  to  eat  the 
food  provided.  Even  if  they  do  submit  to  treatment  in  the 
hospital,  as  soon  as  they  go  home  they  again  take  up  the 
use  of  the  food  to  which  they  are  most  accustomed. 

Appetizing  food  contributes  to  the  medical  cure  of 
the  patients  as  well  as  to  their  comfort  and  happi- 
ness. This  is  particularly  true  in  hospitals  receiving 
chronic  cases  and  in  tuberculosis  sanatoriums.  A  re- 
cent report  of  a  committee  of  the  Conference  of  State 

and  Provincial  Boards  of  Health  said: 

312 


THE  HOSPITAL 

The  sanatorium  should  not  be  considered  primarily  either 
a  hospital  or  a  boarding  house.  It  should  be  so  conducted 
as  to  make  the  patients  satisfied  and  willing  to  stay.  It 
should  be  borne  in  mind  that  happiness  is  essential  to  the 
recovery  of  the  tuberculous. 

There  are  very  considerable  difficulties  in  adapting 
a  hospital  dietary  to  foreign-born  patients.  Several 
different  nationalities  may  be  present  in  the  hospital 
at  the  same  time,  each  represented  by  a  varying 
number  of  patients.  Considering,  however,  the  im- 
portance of  the  food  problem,  it  is  surprising  that  a 
selected  group  of  professionals  in  charge  of  the  diet  in 
a  number  of  leading  hospitals  should  have  given  ap- 
parently so  little  thought  to  the  problem  and  made 
so  little  attempt  to  solve  it. 

Judged  by  the  food  test,  the  American  hospital  has 
not  made  any  noteworthy  effort  to  adapt  itself  to  the 
foreign  born.  Chapter  XI  of  this  book,  devoted  to 
the  food  problem  of  the  foreign  born  in  relation  to 
health,  presents  certain  material  and  practical  sug- 
gestions which  bear  upon  the  hospital  dietary. 

USES   OF  INTERPRETERS 

Another  point  at  which  American  hospitals  can  be 
adapted  to  foreign-born  patients  is  in  the  use  of  inter- 
preters. The  hospital,  as  well  as  the  visiting  nurse, 
must  find  some  way  of  communicating  with  the  patient 
who  speaks  no  English;  but  in  the  case  of  an  institu- 
tion to  which  the  patients  all  come,  it  is  a  simpler 
problem  to  furnish  interpreters  than  to  the  individual 
nurse  who  visits  many  homes.     It  is  relatively  so 

simple  an  administrative  problem  that  it  is  hard  to 

313 


IMMIGRANT  HEALTH  AND  COMMUNITY 

believe  so  little  has  been  done  in  the  country  to 
meet  it. 

A  list  of  30  well-known  hospitals  was  prepared,  each 
located  in  a  city  with  a  large  immigrant  population, 
and  each  known  to  be  receiving  a  considerable  pro- 
portion of  foreign  born.  Inquiry  was  made,  usually 
by  personal  letter,  in  a  few  cases  by  interview. 

Reports  received  from  21  of  the  30  reveal  the  fol- 
lowing condition.  One  hospital  employs  1  paid  in- 
terpreter. This  is  one  of  the  largest  municipal  hos- 
pitals in  the  country,  with  about  2,000  beds  and  a 
very  large  out-patient  department.  Of  course,  the 
employment  of  a  single  interpreter  in  an  institution  of 
this  size,  which  receives  patients  from  practically  all 
immigrant  races,  is  almost  humorously  inadequate. 
Fourteen  of  the  21  hospitals  call  upon  employees  or 
patients  to  interpret  in  various  languages  as  needed. 
Five  hospitals  are  not  doing  anything  at  all  about 
interpreters,  except  occasionally. 

Of  the  14  hospitals  which  depend  on  patients  or 
employees,  4  say  that  the  method  is  not  satisfactory 
in  meeting  their  problem;  10  express  themselves  as 
reasonably  satisfied  with  the  scheme.  In  2  of  these 
10  cases  the  so-called  "star  employee*'  is  mentioned, 
some  one  who  has  been  with  the  hospital  quite  a  while, 
who  is  able  to  speak  a  number  of  languages,  and  who 
is  called  from  his  regular  job,  when  necessary,  to  in- 
terpret. One  large  hospital  has  an  arrangement  with 
the  United  States  Immigration  Office  and  some  local 
organizations  of  the  foreign  born  to  supply  interpre- 
ters whenever  needed. 

These  21  hospitals  are  all  large  institutions,  selected 

because  of  their  location  in  foreign-born  communities. 

314 


THE  HOSPITAL 

Their  work  naturally  suffers  from  the  inadequate  sys- 
tem of  interpretation.  Patients'  names  and  addresses 
are  often  obtained  with  difficulty  or  inaccurately. 
The  medical  history  is  taken  under  great  risk  of  error 
or  omission  if  the  recorder  has  no  knowledge  of  the 
immigrant's  language  and  no  satisfactory  interpreter. 
The  barrier  of  language  raises  serious  obstacles  to 
maximum  efficiency  in  the  administrative  or  medical 
work  of  the  hospital.  This  is  recognized  by  a  con- 
siderable proportion  of  the  superintendents  of  these 
21  hospitals.  Many,  however,  point  out  the  difficul- 
ties in  the  way  of  securing  satisfactory  interpreters. 
One  says: 

We  do  not  employ  paid  interpreters,  but  have  to  struggle 
along  the  best  we  can  by  utilizing  employees  or  other 
patients  for  the  purpose.  Our  experience  in  the  matter 
is  that  the  need  of  interpreters  is  very  irregular  and  widely 
distributed  over  many  languages  and  dialects,  and  we 
have  been  unable  to  formulate  any  working  plan  that  will 
basically  meet  our  needs  and  justify  a  dejfinite  salary  schedule 
to  cover  the  problem.  Hence,  in  making  our  engagements 
with  employees  we  try  to  bear  in  mind  oiu*  need  of  inter- 
preters when  talking  to  applicants. 

Another  says: 

I  took  a  census  of  the  hospital  at  one  time  and  found 
we  had  as  patients  persons  speaking  fifteen  different  tongues, 
and  it  would  take  several  interpreters  to  cover  all  of  these 
languages.  While  we  have  been  inconvenienced  at  times, 
we  usually  get  on  very  well.  For  instance,  I  have  an  Italian 
orderly  in  our  receiving  ward,  and  we  have  had  a  floor 
polisher  who  speaks  two  or  three  of  the  Slavic  dialects.  We 
seem  to  have  no  difficulty  in  handling  the  French  and 
German.  There  is,  of  course,  some  objection  in  taking  a 
man  from  his  work  to  do  interpreting,  and  yet  it  is  less 

315 


IMMIGRANT  HEALTH  AND   COMMUNITY 

expensive  than  having  a  special  interpreter.  I  think  that 
I  can  safely  say  that  for  a  considerable  time  our  records 
have  not  suffered  from  the  fact  that  we  could  not  get  a 
history  on  account  of  the  language. 

These  two  letters  point  out  some  practical  reasons 
why  hospitals  have  so  generally  failed  to  employ  paid 
interpreters,  and  have  depended  so  largely  upon  em- 
ployees or  patients  who  speak  the  needed  languages. 
However,  the  admitting  officer  or  the  hospital  internes 
must  secure  information  concerning  the  medical  and 
social  history  of  the  patient  which  an  uneducated  in- 
terpreter is  often  wholly  unable  to  obtain.  Whether 
in  this  respect  or  in  meeting  the  patients'  human  needs, 
good  interpretation  can  rarely  be  secured  by  this  cas- 
ual system. 

Another  attempt  at  solving  the  problem  is  illus- 
trated by  the  following  statement  from  a  large  general 
hospital  in  a  Middle  Western  city. 

We  do  not  employ  paid  interpreters.  Occasionally  we 
do  use  employees  or  other  patients,  but  in  the  majority  of 
instances  we  rely  upon  other  associations  in  the  city  for 
this  work.  The  various  councils  give  their  services  gratis 
in  cases  of  necessity;  and  other  institutions,  such  as  the 
House  of  Friendliness,  the  Americanization  Society,  and 
similar  organizations,  will  send  interpreters  to  the  hospital 
on  request,  who  give  their  services  without  charge.  We 
have  found  this  arrangement  to  be  very  satisfactory,  but 
I  imagine  that  in  some  of  the  larger  cities  where  this  problem 
is  a  more  difficult  one  the  question  of  a  paid  interpreter 
would  receive  very  earnest  consideration. 

It  is  apparent  that  in  overcoming  the  language 

barrier  a  certain  number  of  hospitals  have  made  a 

distinct  effort,  and  the  hospitals  show  up  much  better 

316 


THE  HOSPITAL 

in  this  respect  than  in  dealing  with  the  food  problem. 
Yet  it  is  again  apparent,  generally  speaking,  that  hos- 
pitals have  dealt  with  the  problem  of  interpretation 
only  as  a  succession  of  incidental  emergencies  which 
had  to  be  met  as  well  as  possible,  on  the  spur  of  the 
moment,  by  utilizing  employees  or  patients  without 
any  systematic  plan. 

One  reason  that  even  large  hospitals  have  considered 
it  financially  impossible  to  maintain  a  corps  of  paid 
interpreters  has  been  their  failure  to  realize  the  full 
use  to  which  these  might  be  put.     Hospitals  having 
large  out-patient  departments,  with  many  patients 
who  speak  no  English,  have  too  often  regarded  them 
as  a  subsidiary  or  unimportant  element  in  their  work, 
and  starved  them  financially.    Taking  the  patients  of 
the  hospital  and  the  out-patient  department  together, 
the  number  of  those  speaking  a  given  foreign  language 
is  sometimes  sufficient  to  require  the  entire  time  of  an 
interpreter.     The  use  of  full-time  interpreters,  how- 
ever,   must    necessarily    be    limited    to    very    large 
institutions. 

Smaller  hospitals  should  solve  the  problem  of  in- 
terpretation by  depending  upon  specially  trained 
nurses  or  social  workers  or  upon  outside  organizations 
interested  in  or  composed  of  the  foreign  born.  The 
latter  should  be  encouraged  to  visit  patients  of  their 
own  race  who  have  no  other  friends,  and  to  help  with 
difficult  and  special  cases  where  interpretation  is  be- 
yond the  power  of  the  hospital  employees.  Enough 
hospitals  use  this  sort  of  outside  co-operation  to  show 
that  it  is  gladly  provided  by  immigrant  organizations 
and  by  American  immigrant-welfare  societies,  without 

cost  to  the  hospital  and  with  mutual  benefit.    Such  an 

317 


IMMIGRANT  HEALTH  AND  COMMUNITY 

arrangement  will  promote  general  understanding  of 
the  hospital  among  the  foreign-born  groups. 


SOCIAL-SERVICE   DEPARTMENT 

In  addition  to  the  special  adaptation  necessary  to 
overcome  the  difficulties  of  diet  and  language,  every 
hospital  receiving  immigrants  should  have  a  social- 
service  department  to  establish  human  relations  with 
each  patient.  Yet  despite  the  fact  that  all  leaders  in 
medical  and  public-health  work  to-day  recognize  the 
necessity  for  social  service  in  hospitals,  there  are  only 
some  three  hundred  hospitals  in  this  country  which 
have  such  departments. 

Such  a  department  can  work  effectively  only  when 
it  is  intimately  associated  with  the  hospital  adminis- 
tration in  general,  and  not  an  isolated  and  subsidiary 
element  helping  individual  patients  whose  needs  have 
attracted  special  attention.  The  head  of  the  depart- 
ment should  be  directly  responsible  to  the  hospital 
superintendent.  The  workers  should  be  chosen  for 
their  skill  and  training  in  dealing  with  the  personal 
and  social  problems  of  people.  The  department 
should  be  charged  with  special  responsibilities  for 
foreign-born  patients;  not  merely  case  work  in  the 
wards,  but  also  certain  functions  at  the  admission 
desk  of  the  hospitals  and  the  development  and  main- 
tenance of  effective  co-operation  with  certain  outside 
agencies. 

At  the  admission  desk  it  is  important  to  obtain  a 

considerable   amount   of   information   regarding  the 

patient's  personality,  family,  occupation,  and  resources, 

for  the  sake  of  the  hospital's  medical  work  and  financial 

318 


THE  HOSPITAL 

returns,  and  also  for  the  sake  of  the  patient's  care  and 
after-care.  It  is  often  impossible  to  secure  all  these 
necessary  facts  at  the  moment  when  a  very  sick 
patient  is  admitted,  but  the  deficiency  can  usually  be 
supplied  later.  The  facts  gathered  by  the  social  worker 
at  the  admission  desk  must  be  put  to  a  much  broader 
service  than  merely  to  determine  what  the  patient 
can  pay  the  hospital  for  care.  When  properly  secured, 
such  knowledge  furnishes  hospital  and  patient  a  basis 
for  mutual  understanding  and  for  the  best  medical 
and  social  results. 

This  work  for  the  foreign  born  should  be  in  the 
hands  of  some  one  who  is  able  to  speak  at  least  one 
of  the  foreign  languages  common  among  the  patients, 
and  who  has  studied  the  backgrounds  and  character- 
istics of  several  immigrant  races.  It  should  be  her 
responsibility  also  to  help  and  encourage  various  hos- 
pital employees,  nurses,  other  members  of  the  social- 
service  department,  and  internes,  to  secure  knowledge 
about  the  backgrounds  and  characteristics  of  the  chief 
immigrant  groups.  It  should  be  made  apparent  that 
thus  better  histories  can  be  obtained,  better  co-opera- 
tion of  the  patient  secured,  and  better  medical  results 
achieved.  These  measures  should  have  the  support 
not  only  of  the  hospital  superintendent,  but  of  the 
chiefs  of  the  medical  staff. 

The  same  individual  of  the  social-service  depart- 
ment should  develop  co-operation  with  outside  immi- 
grant organizations,  with  immigrant  welfare  societies, 
or  with  both. 

Most  hospitals  have  been  founded  primarily  for 

the  care  of  acutely  sick  patients.    The  attention  of 

their  medical  and  administrative  staffs  has  been  cen- 

319 


IMMIGRANT  HEALTH  AND  COMMUNITY 

tered  upon  the  outstanding  items  of  disease.  The 
need  for  after-care  of  patients  following  discharge 
from  the  hospital,  for  social  service,  and  in 
general  for  the  development  of  relationships  between 
the  hospital  and  the  community  outside  has  been 
slow  of  effective  recognition  in  most  medical  in- 
stitutions. 

Hospital  organization  is  generally  of  a  somewhat 
rigid  and  military  character.  This  is  true  not  only  in 
the  operating  room,  where  such  might  be  expected 
and  necessary,  but  in  the  general  administration  of 
the  hospital.  Hospitals  have  rarely  functioned  in 
close  co-ordination  with  other  organizations  in  a  gen- 
eral community  scheme  for  medical  service.  The 
usual  unresponsiveness  of  hospitals  to  the  special  needs 
of  foreign-born  patients  is  merely  one  illustration  of 
this  characteristic. 

Anyone  even  slightly  familiar  with  hospitals  can 
call  to  mind  numerous  instances  of  devoted  attention 
by  doctors  and  nurses  to  individual  patients,  and  of 
much  personal  interest  in  their  welfare.  Grave  or 
unusual  illness  calls  forth  ready  and  unstinted  re- 
sponse. A  patient  whose  personality  is  appealing 
naturally  receives  attention  and  evidence  of  interest 
irrespective  of  the  seriousness  of  his  case. 

It  is,  however,  the  duty  of  a  hospital  organization 
to  provide  for  the  average  patient  in  human  as  well 
as  in  technical  medical  ways.  Imagine  an  Italian  or 
Pole  who  lies  ten  days  or  three  weeks  in  a  ward  amid 
strange  surroundings,  unable  to  speak  English.  He 
receives  food  which  is  unfamiliar  and  often  distaste- 
ful, however  well  prepared  from  the  American  point 

of  view.    Perhaps  he  is  without  friends  who  can  talk 

320 


THE  HOSPITAL 

to  him  even  at  the  necessarily  infrequent  periods  when 
ward  visitors  are  allowed. 

Is  not  such  a  patient  humanly  pitiable?  Must  not 
the  promptest  post-operative  convalescence,  or  return 
to  health  after  any  serious  illness,  be  retarded  by  such 
conditions?  The  best  medical  results  for  the  patient 
require  that  he  comprehend  the  doctor's  directions  as 
to  diet,  work,  and  regime  of  life,  after  he  is  discharged 
from  the  hospital.  Failure  to  understand  these  direc- 
tions may  mean  that  much  of  the  hospital's  effort  is 
wasted. 

IMMIGRANT   HOSPITALS 

Some  of  the  objections  expressed  by  immigrants  are 
met  by  hospitals  run  by  members  of  their  o^ti  nation- 
alities. In  several  large  cities  immigrants  of  a  given 
group,  who  have  been  in  sufficient  numbers  and  pos- 
sessed of  sufficient  means,  have  developed  special 
hospitals  for  their  own  people. 

The  Jews  have  estabHshed  their  own  hospitals  in 
most  of  the  large  centers  of  Jewish  population.  The 
dietary  laws  of  the  Jew  furnish  a  special  reason  why 
the  orthodox  Hebrew  objects  to  going  to  "American" 
hospitals.  It  is  notable,  however,  that  most  of  the 
larger  hospitals  put  up  and  supported  by  Jewish 
people  do  not  provide  a  strictly  kosher  diet,  as  food 
prepared  according  to  the  Jewish  dietary  laws  is  called. 
This  is  partly  because  of  practical  culinary  difficulties 
and  partly  because  these  hospitals  have  in  most  in- 
stances been  put  up  and  are  chiefly  supported  by 
groups  of  Jews  who  no  longer  observe  the  dietary 
laws  strictly,  if  at  all.    On  this  account  a  movement 

is  on  foot  in  several  cities  to  establish  hospitals  in 

321 


IMMIGRANT  HEALTH  AND  COMMUNITY 

which  there  is  strict  conformity  to  the  Jewish  dietary 
regime.  In  New  York  several  kosher  hospitals  are 
well  established.  In  Chicago  the  gradual  rise  in  num- 
bers, wealth,  and  influence  of  the  orthodox  Jewish 
immigration  has  recently  resulted  in  a  similar  kosher 
hospital  independent  of  the  long-established  Michael 
Reese  Hospital. 

In  New  York  City  we  find  the  Italian  Hospital.  In 
several  other  cities  where  the  Italians  are  newer  and 
not  so  numerous  as  in  New  York,  a  number  of  efforts 
can  be  traced  to  found  such  hospitals,  supported  by 
and  for  Italians.  There  are  hospitals  supported  by 
Poles  or  closely  associated  with  Polish  groups  in 
Chicago,  Detroit,  Cleveland,  Buffalo,  and  elsewhere. 
The  Japanese  colony  in  San  Francisco  is  developing 
plans  for  its  own  hospital.  The  desire  of  the  Japanese 
to  come  close  to  the  American  community  is  illus- 
trated by  their  efforts  to  affiliate  this  proposed  hos- 
pital with  the  University  Hospital  in  San  Francisco, 
thus  providing  opportunities  for  well-trained  Japanese 
physicians,  while  also  utilizing  the  services  of  Ameri- 
can physicians  of  standing. 

'  In  smaller  communities  individual  physicians  main- 
tain small  private  hospitals  for  people  of  their  own 
race.  The  demand  of  the  older  generations  for  a 
hospital  run  by  their  own  people,  and  furnishing  their 
familiar  foods,  is  often  reinforced  by  the  desire  of 
doctors  of  the  same  race  to  have  opportunities  for 
hospital  work  and  experience  which  most  of  them 
cannot  secure  at  the  "American'*  institutions. 

The  endeavors  of  foreign-born  groups  to  develop 
their  own  hospitals  should  not  be  interpreted  as  merely 

a  desire  to  perpetuate  their  own  nationality  in  this 

322 


THE  HOSPITAL 

country  or  to  keep  their  people  from  contact  with 
America.  The  estabHshment  of  Jewish,  Polish,  or 
Italian  hospitals  springs  rather  from  the  failure  of 
nearly  all  American  hospitals  to  adapt  themselves  to 
the  special  demands  of  the  immigrant. 

NEED    FOR   A    COMMUNITY   PLAN 

The  desirability  of  separate  immigrant  hospitals  must 
be  finally  judged  by  its  effect  upon  the  best  medical 
service  to  the  community.  Many  small  unrelated 
hospital  units,  each  serving  a  special  group,  are  not 
so  efficient  as  a  smaller  number  of  large  related  units. 

If  a  community  has  ten  hospitals  of  from  fifty  to 
one  hundred  beds,  each  can  command  only  a  limited 
amount  of  the  highest  grade  of  medical  service  in  the 
various  branches  of  modern  medicine  and  surgery. 
Most  of  them  will  find  it  hard  to  provide  adequate 
laboratory  and  X-ray  facilities  and  other  expensive 
but  necessary  diagnostic  and  therapeutic  equipment. 
They  cannot  readily  secure  the  best  grade  of  skill  for 
their  executive  officer,  for  the  head  of  the  nurses' 
training  school,  or  for  the  various  housekeeping 
departments. 

The  location  of  each  is  likely  to  be  planned  inde- 
pendently, without  relation  one  to  another  or  to  the 
needs  of  the  community  as  a  whole.  The  distribution 
of  beds  among  the  various  types  of  medical  and  sur- 
gical service  cannot  be  nearly  so  effective  in  ten  small 
independent  units  as  in  three  or  four  large  ones. 

It  is  difficult  to  bring  ten  small  institutions  into 

effective  co-ordination  one  with  another  and  with  the 

outside  medical  and  health  agencies  of  the  community. 

323 


IMMIGRANT  HEALTH  AND  COMMUNITY 

This  is  particularly  true  if  several  of  these  ten  hospitals 
have  special  affiliations  with  race  groups. 

There  must  be  a  hospital  plan  for  the  community 
as  a  whole.  The  scheme  for  the  town  of  ten  thousand 
will  differ  radically  from  that  for  a  great  city,  but  no 
hospital  can  work  at  any  problem,  such  as  adaptation 
to  foreign-born  patients,  with  full  effectiveness,  unless 
most  or  all  of  the  hospitals  of  the  community  are 
working  with  it.  Such  a  community  plan  is  discussed 
in  a  later  chapter  and  applies  to  hospitals  as  well  as 
other  institutions. 

At  the  opening  of  this  chapter  hospitals  were  classi- 
fied under  two  fundamental  types — public  service  and 
proprietary  hospitals.  The  direct  bearing  of  this 
study  has  been  obviously  upon  hospitals  of  the  first 
class;  but  in  many  large  cities  a  considerable  number 
of  the  hospitals  are  proprietary,  and  not  a  few  of  the 
smaller  communities  have  no  other  hospital  facilities. 
Clearly,  a  hospital  which  is  established  as  a  business 
enterprise  can  serve  only  those  who  can  afford  to  pay 
a  profit  as  well  as  a  price  for  their  care.  Individual 
charity  cases  can  be  taken  but  rarely. 

Proprietary  hospitals  cannot  be  expected  to  adapt 
their  service  to  any  special  group  of  patients  except 
on  a  business  basis.  Either  the  community  must 
establish  its  own  hospital  or  else  arrange  with  one  or 
more  of  the  proprietary  institutions  to  take  part- 
paying  or  free  cases  at  public  expense.  Such  arrange- 
ments are  not  infrequent,  the  proprietary  hospital  re- 
ceiving a  per  capita  return  for  this  public  service 
from  the  municipality,  the  county,  or  an  industrial 
establishment. 

Such  arrangements,  however,  do  not  render  the 

324 


THE  HOSPITAL 

administration  of  the  hospital  sufficiently  sensitive 
to  community  needs  and  to  the  requirements  of  par- 
ticular types  of  patients,  the  foreign  born  among 
others.  The  only  adequate  remedy  for  this  situation 
is  the  relegation  of  the  proprietary  hospital  to  its 
proper  sphere  of  serving  the  well-to-do,  and  the  de- 
velopment in  all  communities,  or  at  centers  accessible 
to  all,  of  hospitals  founded  primarily  on  a  public- 
service  basis. 
22 


XV 

THE   DISPENSARY 

The  increase  in  the  number  of  dispensaries  in  the 
United  States  during  the  last  twenty  years  has  been 
one  of  the  outstanding  features  in  medical  and  public- 
health  work.  The  earliest  dispensaries,  as  the  name 
implies,  were  places  for  distributing  medicine  to  the 
poor.  The  modern  dispensary  includes  a  group  of 
clinics  for  treatment  in  most  or  all  of  the  chief  spe- 
cialties of  medicine  and  surgery.  The  giving  of  medi- 
cine is  now  incidental.  The  modern  dispensary  is  a 
place  for  organized,  or  institutional,  medical  service 
to  patients  who  are  able  to  be  up  and  about.  It  is 
an  institution  complementary  to  the  hospital,  whose 
patients  are  in  such  condition  that  they  must  be  in 
bed. 

Most  of  the  larger  dispensaries  are  branches  or,  as 
they  are  called,  out-patient  departments  of  hospitals. 
Some  of  equal  size  are  independent  of  hospitals.  The 
growth  of  these  institutions  has  been  very  consider- 
able; at  the  opening  of  the  twentieth  century  their 
number  did  not  much  exceed  one  hundred,  whereas 
in  1917  there  were  about  nine  hundred  in  the  United 
States.^  The  greater  number  of  these  were  in  the 
larger  cities,  particularly  in  the  East  and  Middle  West. 

^  Davis  and  Warner,  Dispensaries,  Their  Management  and 
Development,  pp.  4-36. 

326 


THE  DISPENSARY 

Even  more  striking  has  been  the  development  of 
the  public-health  dispensaries,  established  as  the  out- 
come of  one  or  another  of  the  militant  health  move- 
ments, such  as  the  antituberculosis  or  infant-welfare 
campaigns.  These  clinics  are  usually  local  in  their 
range  of  operation,  and  small  compared  with  the  large 
dispensaries  treating  general  diseases.  They  were 
practically  unknown  before  1900.  A  few  tuberculosis 
clinics  had  been  started  previous  to  that  year — not 
more  than  twenty  in  the  whole  country.  By  1917 
there  were  estimated  to  be  thirteen  hundred  of  these 
various  special  dispensaries,  and  the  number  was 
greatly  increased  during  the  war,  owing  to  the  stimu- 
lus given  to  campaigns  against  infant  mortality  and 
venereal  disease. 

Some  of  the  public-health  dispensaries  confine  their 
attention  to  preventive  and  educational  work,  such 
as  advice  to  mothers  concerning  the  care  of  babies 
and  the  supervision  of  baby  feeding.  But  the  tuber- 
culosis, venereal  disease,  and  mental  clinics,  and  to 
a  greater  or  less  extent  the  infant-welfare  clinics 
themselves,  diagnose  and  treat  disease  as  well  as  push 
educational  and  preventive  measures. 

It  is  important  to  bear  in  mind  the  general  distinc- 
tion between  the  large,  centrally  located  dispensary, 
usually  an  out-patient  department  of  a  hospital,  treat- 
ing patients  in  many  specialties  of  medicine  and  sur- 
gery, and  the  public-health  clinic,  usually  drawing  its 
patients  from  a  limited  area  and  confining  itself  to 
a  special  branch  of  work.  A  third  type  combines 
features  of  the  first  two.  It  is  the  dispensary  of  mod- 
erate size,  including  a  certain  number  of  specialties  as 

well  as  general  clinics,  and  reaching  a  more  or  less 

327 


IMMIGRANT  HEALTH  AND  COMMUNITY 

comprehensive,  but  still  definitely  localized,  area. 
The  term  "Health  Center,'*  which  is  now  heard  so 
frequently,  suggests  a  combination  of  various  forms 
of  medical  and  health  work,  such  as  a  number  of  dif- 
ferent public-health  clinics  in  the  same  building,  either 
with  or  without  clinics  giving  treatment  in  various 
branches  of  medicine. 

Dispensaries  have  differed  from  hospitals  signifi- 
cantly in  the  matter  of  clientele.  The  hospital  gener- 
ally accepts  patients  from  all  economic  classes :  those 
who  can  pay  whatever  is  demanded  go  to  individual 
rooms  as  private  patients;  those  who  can  pay  nothing 
or  only  the  so-called  ward  rate  go  into  large  wards; 
persons  in  middle  circumstances  pay  enough  for  small 
wards  or  semiprivate  rooms,  if  the  hospital  has  such. 

With  a  very  few  notable  exceptions  dispensaries 
have  limited  their  clientele  to  those  who  can  pay  little 
or  nothing  for  medical  service.  Nominal  fees  are  often 
charged,  ten  cents  or  twenty-five  cents  a  visit,  with 
or  without  small  extra  charges  for  medicines  or  special 
treatment;  but  the  dispensary  has  been  regarded,  and 
has  generally  been  operated,  as  an  institution  for 
medical  relief  of  the  poor,  rather  than  an  institution 
providing  medical  care  for  every  social  class,  and  re- 
ceiving from  each  class  according  to  its  means.  Con- 
sidering the  difficulty  which  many  immigrants  have 
'  in  obtaining  or  in  paying  for  adequate  medical  service, 
\  one  might  feel  that  the  dispensary  was  peculiarly 
{     called  upon  to  serve  the  immigrant. 

We  have  seen  something  of  the  immigrant's  attitude 
toward  hospitals.  Many  of  the  same  objections  are 
raised  against  dispensaries.  The  distance  and  strange- 
ness of  the  place,  the  inability  to  understand  or  to 

328 


THE  DISPENSARY 

make  oneself  understood,  and  the  fear  that  doctors 
"practice  on  you,'*  are  all  brought  out  in  immigrant 
testimonies.  The  long  waiting  before  treatment  is  an 
additional  objection  to  the  dispensary.  This  becomes 
a  serious  problem  for  mothers,  when  children  must 
either  be  brought  along  or  left  at  home  in  the  care  of 
a  busy  neighbor  or  of  children  too  young  to  take  the 
responsibility.     A  Polish  woman  says: 

Mrs.  C.  was  referred  to  the  dispensary  by  the  public 
charities.  She  had  complained  of  blurring  eyes  and  splitting 
headaches.  The  doctors  in  her  neighborhood  could  not 
help  her  and  the  neighbors  had  told  her  all  they  knew  about 
patent  medicines.  Since  she  came  to  the  dispensary  she 
felt  better,  but  it  is  so  far  and  the  car  fare  is  expensive. 
Besides,  not  being  able  to  read  and  write,  she  does  not 
know  what  car  to  take,  and  the  neighbors,  although  they 
were  willing  to  come  with  her  the  first  time,  find  that  they 
are  too  busy  to  give  all  the  morning.  Then,  of  course,  she 
cannot  speak  English  and  does  not  like  to  explain  to  every- 
one why  she  cannot  pay.  So  she  had  rather  stay  at  home 
and  suffer. 

From  an  Italian  comes  this  testimony: 

Family  have  used  several  dispensaries.  Her  husband  for 
his  eyes,  she  for  herself  and  her  children.  When  her 
children  were  babies  she  used  to  go  there  for  their  feeding, 
as  she  could  not  nurse  them.  She  does  not  like  their 
methods  of  treatment.  She  feels  that  the  doctors  are 
students  and  experiment  on  the  patients.  Her  child  didn't 
improve,  so  she  took  her  to  a  private  doctor.  Then,  too, 
she  says  that  one  has  to  waste  so  much  time  waiting  before 
being  treated.  On  the  whole,  though  the  private  doctor 
charges  more,  one  remains  more  satisfied. 

A  Ukrainian  doctor  says: 

Attitude  toward  dispensaries  much  the  same  as  toward 
hospitals:   thev  feel  very  strange  and  lost;   the  doctors  do 

329 


IMMIGRANT  HEALTH  AND  COMMUNITY 

not  speak  the  language;  and  when  the  history  of  a  case  has 
to  be  taken  through  an  interpreter  there  is  so  much  talk 
going  on  which  the  patient  does  not  understand  that  he 
goes  away  bewildered  and  discouraged.  The  dispensaries 
are  not  usually  very  near,  the  hours  may  not  be  convenient, 
there  is  the  long  waiting  in  line,  and  again  the  suggestion 
of  charity. 

A  Jewish  doctor  says: 

In  regard  to  the  dispensaries,  the  Jewish  attitude  is  quite 
different,  and  the  people  flock  to  them.  They  know  they 
will  receive  the  care  of  a  specialist,  a  professor,  and  they 
are  only  too  glad  to  avail  themselves  of  the  opportunity. 
There  the  mother  can  go  into  the  clinic  with  the  child 
and  is  permitted  to  talk  and  explain  herseK  freely. 


USE  BY  IMMIGRANTS 

In  spite  of  these  attitudes,  one  of  the  striking  fea- 
tures of  dispensary  work  is  the  wide  variety  of  nation- 
alities cared  for  and  the  large  proportion  of  foreign 
born  among  the  patients  of  many  typical  institutions. 
Thus,  at  the  Boston  Dispensary,  which  receives  about 
35,000  patients  a  year  in  its  out-patient  clinics,  84 
different  nationalities  were  represented  during  one 
recent  year;  45  per  cent  of  all  the  patients  were 
foreign  born,  but  30  per  cent  additional  were  the 
native-born  children  of  immigrants,  only  one  fourth 
of  the  total  clientele  being  of  native  stock.  This  pro- 
portion is  not  dissimilar  to  that  which  obtains  in  the 
local  population. 

There  are,  of  course,  some  large  dispensaries,  in  New 
York  City,  for  example,  where,  because  of  the  neigh- 
borhood or  the  racial  affiliations  of  the  dispensary,  a 

vast  majority  of  the  patients  are  of  a  single  racial 

330 


THE  DISPENSARY 

group.  But  the  polyglot  nature  of  the  assemblage  in 
the  admission  hall  cannot  fail  to  impress  the  visitor 
to  almost  any  of  the  larger  dispensaries  in  New  York, 
Chicago,  Baltimore,  Philadelphia,  Cleveland,  St. 
Louis,  or  San  Francisco. 

With  a  view  to  understanding  the  order  and  rate  of 
the  immigrant's  acquaintanceship  with  American 
medical  resources,  it  is  interesting  to  ascertain  the 
relative  use  of  dispensaries  by  different  racial  groups. 
Some  valuable  figures  have  been  obtained  from  one 
of  the  largest  dispensaries  in  Chicago.^  Out  of  2,535 
consecutive  cases,  1,055  were  from  6  chief  immigrant 
groups : 

TABLE  XXX 

NuiiBER  AND  Per  Cent  of  1,055  Cases  Treated  by  the  Central 
Free  Dispensary,  Rush  Medical  College,  by  Nationality 


Natioxality 

NTTiTBER 

Per  Cent 

Polish 

343 
333 
182 
115 
57 
25 

32.5 

Jewish 

31.6 

Italian 

17.3 

Bohemian 

10.9 

Lithuanian 

5.4 

Greek 

2  4 

Total 

1,055 

100.0 

It  will  be  noticed  that  the  number  of  Jews  and  Poles 
are  nearly  equal.  Investigation  of  the  sources  from 
"which  the  patients  came,  or  of  the  reasons  for  their 
coming,  disclosed  the  following  facts.  More  than  55 
per  cent  of  the  Poles  were  sent  to  the  dispensary  by 

^  The  co-operation  of  Mr.  John  E.  Ranson,  superintendent  of  the 
Central  Free  Dispensary  of  Rush  Medical  College,  is  gratefully 
acknowledged  in  this  connection. 

331 


IMMIGRANT  HEALTH  AND  COMMUNITY 

some  agency,  usually  the  Board  of  Education.  Among 
the  Jews,  on  the  other  hand,  only  13  per  cent  had 
come  from  agencies,  the  large  majority  having  come 
to  the  dispensary  on  their  own  initiative.  The  Italians 
occupy  a  middle  ground  between  the  Jews  and  the 
Poles,  45  per  cent  having  been  referred  by  an  agency. 
Among  the  Polish  patients  only  10  per  cent  were  forty- 
five  years  of  age  or  over,  and  45  per  cent  were  children 
of,  or  under  school  age,  who  came  to  the  dispensary 
either  to  secure  medical  examination  for  working 
papers  or  because  the  school  doctor  or  nurse  had  re- 
ferred them  for  medical  care.  The  percentages  among 
the  Bohemians  and  the  Lithuanians  were  practically 
the  same  as  for  the  Poles.  Among  the  Jews,  20  per 
cent  were  over  forty-five,  and  only  10  per  cent  were 
children. 

The  percentage  of  Jewish  patients  among  the  total 
patients  of  the  Boston  Dispensary  was  found  to  be 
just  about  twice  as  great  as  the  proportion  of  Jews  in 
the  city  population. 

Figures  secured  in  the  study  of  the  dispensaries  of 
New  York  City,  conducted  by  Dr.  E.  H.  Lewinski- 
Corwin,  under  the  auspices  of  the  New  York  Academy 
of  Medicine,  and  generously  placed  at  our  disposal, 
showed  the  type  of  treatment  secured  by  3,536  suffer- 
ers from  various  ills  in  New  York  City,  by  nationality. 
The  number  using  dispensaries  is  compared  with  the 
number  using  hospitals  by  race  (Table  XXXI) . 

From  all  these  figures  it  is  apparent  that  of  the 

three  large  recent  immigrant  groups,  the  Jews  are  far 

and  away  the  greatest  users  of  dispensaries;  the  Poles 

and  other  Slavs  use  them  least;   the  Italians  occupy 

a  middle  division.    Long  residence  in  the  country  in- 

332 


THE  DISPENSARY 

fluences  the  situation,  by  increasing  familiarity  with 
the  language  and  with  the  existence  and  location  of 
the  dispensaries  themselves.  The  nature  of  their  work 
gradually  becomes  known  through  the  stories  of 
friends  and  acquaintances.  Individuals  and  races 
differ  obviously  in  their  readiness  to  seek  opportunity. 
The  keenness  of  the  Jew  in  this  respect,  combined 
with  a  sensitive  organism  which  impels  him  to  seek 

TABLE  XXXI 

Number  and  Per  Cent  of  3,536  New  York  City  Cases  Using 
Hospitals  and  Dispensaries,  by  Nationality 


Nationality 

Total 

Number 
OF  Cases 

Using  Dis- 

PENSAEY 

Using  Hos- 
pital 

Number 

Per  Cent 

Number 

Per  Cent 

Irish 

209 
596 
193 
575 
215 
243 
844 
661 

40 
99 
25 
69 
20 
18 
26 
14 

19.1 

16.6 

13.0 

12.0 

9.3 

7.4 

3.1 

2.1 

19 
36 
20 
67 
14 
19 
44 
15 

9.1 

U.S.  A 

Neffro     

6.0 
10.4 

Hebrew     

11.7 

CrprTnan       

6.5 

IVTispellaneous 

7.8 

Italiaii       

5.2 

Slav 

2.3 

Total     

3,536 

311 

8.8 

234 

6.6 

prompt  relief  from  illness  or  suffering,  may  account, 
at  least  in  part,  for  his  occupying  first  place  numeri- 
cally in  the  immigrant  clientele  of  dispensaries. 

One  of  the  motives  which  lead  persons  to  dispen- 
saries for  medical  care  is  economic.  They  may  go 
because  they  haven't  the  money  to  pay  for  a  private 
doctor,  or  because  they  have  been  to  a  private  doctor 
and  have  been  dissatisfied  with  their  treatment  and 
have  very  little  ready  money  left.  The  desire  to 
secure  high-class  medical  treatment  is  another  pov/er- 

333 


IMMIGRANT  HEALTH  AND  COMMUNITY 

ful  motive.  They  seek  the  dispensary  because  the 
name  of  a  famous  doctor  is  attached  to  it;  or  some- 
thing is  the  matter  with  the  eye  or  other  special  organ, 
and  they  know  they  cannot  afford  the  high  rates 
charged  by  speciahsts  at  their  private  offices.  The 
dispensary,  in  fact,  offers  the  only  opportunity  for 
most  persons  of  small  means  to  see  specialists. 

Other  motives  operate  to  keep  both  native  and 
foreign  born  away  from  dispensaries.  The  dislike  of 
receiving  charity  is  one;  others  are  the  inconveniences 
of  waiting,  of  being  crowded,  of  having  less  privacy 
than  in  a  doctor's  office,  all  conditions  frequently 
found  in  dispensaries  at  the  present  time.  The  special 
deterrents  caused  by  barriers  of  language,  ignorance, 
superstitution,  or  fear,  have  often  been  referred  to. 

The  dispensary  cannot  be  regarded  as  merely  an 
institution  for  furnishing  medical  charity.  It  is  an 
institution  for  furnishing  medical  service  to  those  who 
need  it,  and  from  this  standpoint  it  is  not  only  its 
privilege,  but  its  duty,  to  adapt  itself  to  their  needs. 
Keeping  in  mind  the  immigrant  point  of  view,  let  us 
ask  what  dispensaries  in  America  have  done  to  adapt 
themselves  to  the  immigrant,  and  what  they  can  do; 
what  has  been  the  point  of  view  of  doctors,  nurses, 
social  workers,  and  administrators  toward  the  immi- 
grant; what  their  understanding  of  his  personality 
and  needs;  what  their  effort  to  give  him  what  he 
needs  in  an  acceptable  manner  .^^ 

MEETING  THE  NEEDS  OF  INDIVIDUALS 

Many  hospitals  suffer  from  institutionalism  or  over- 
organization   along   military   lines,   and    consequent 

inflexibility  to  the  needs  of  the  individual.     Dispen- 

334 


THE  DISPENSARY 

saries  are  liable  to  the  opposite  defect,  of  under- 
organization;  a  loose  and  careless  manner  of  running. 
Hundreds  of  patients  pour  into  the  waiting  room; 
their  names  and  addresses  are  hastily  entered  by  a 
clerk;  they  are  moved  along  as  rapidly  as  possible 
to  the  waiting  rooms  of  various  clinics;  they  wait 
until  the  doctors  arrive  and  then  until  the  doctors  are 
ready  to  see  them.  Sometimes  they  wait  a  long  time; 
see  the  doctors,  who  are  perhaps  in  a  hurry;  some  get 
advice;  perhaps  understand  some  of  it;  very  likely  get 
a  prescription  for  medicine;  get  the  medicine;  go 
home.  The  three  outstanding  impressions  given  by 
the  average  dispensary  to  the  average  patient  are 
much  crowding,  much  waiting,  much  hurry. 

These  conditions  have  been  remedied  to  a  great 
extent  in  recent  years  in  the  better  dispensaries,  but 
they  still  prevail  much  too  widely,  particularly  in  the 
larger  institutions.  They  are  due  chiefly  to  the  lack 
of  adequate  administrative  staffs,  and  the  fact  that 
the  doctors  are  usually  unsalaried  and  cannot  afford 
to  give  sufficient  time.  In  these  respects,  lack  of  adap- 
tation to  the  needs  of  the  foreign-bom  patients  is 
merely  part  of  a  general  level  of  inefficiency  which 
applies  to  all  patients.  But  the  results  of  such  in- 
efficiency are  usually  more  serious  for  the  foreign  born 
than  for  the  native  born. 

The  aim  is  to  get  results  in  treatment,  not  merely 
to  see  patients  and  diagnose  their  diseases.  Success 
depends  not  only  upon  the  doctor's  skill  and  wisdom, 
but  upon  the  patient's  understanding  his  directions 
and  the  patient's  intellectual  and  financial  ability  to 
carry  out  these  directions. 

The  doctor's  hastily  spoken  directions  may  be  80 

335 


IMMIGRANT  HEALTH  AND  COMMUNITY 

per  cent  understood  by  an  American  with  a  good 
common-school  education.  The  same  directions  might 
be  50  per  cent  understood  by  an  Italian  workman 
who  had  picked  up  a  knowledge  of  English  but  had 
never  been  to  school.  They  might  be  less  than  20 
per  cent  understood  by  a  Jewish  or  Polish  woman 
who  spoke  only  a  few  words  of  English,  knew  little  of 
the  doctor's  vocabulary,  and  nothing  of  the  conditions 
to  which  he  referred.  The  medical  results  of  treat- 
ment would  necessarily  differ  in  these  three  cases.  As 
an  organization  aiming  for  efficiency  in  medical  re- 
sults, it  is  the  dispensary's  business  to  equalize  so  far 
as  possible  the  patients*  ability  to  understand  instruc- 
tions and  to  carry  them  out. 

MEDIUMS   OF   COMMUNICATION 

The  first  and  most  obvious  effort  which  dispensaries 
have  made  to  overcome  the  difficulties  of  dealing  with 
the  foreign  born  has  been  against  the  barrier  of 
language.  Signs  in  different  languages,  directing 
patients  where  to  go,  are  an  administrative  conven- 
ience usually  found  in  dispensaries.  The  use  of  leaflets 
on  the  feeding  of  babies,  and  the  care  and  prevention 
of  tuberculosis  or  venereal  diseases,  already  referred 
to  in  connection  with  field  work,  is  fairly  frequent  in 
dispensaries.  Foreign-speaking  doctors  have  been 
employed  in  not  a  few  institutions.  For  interpreters, 
dispensaries  generally  have  depended  upon  some  em- 
ployee or  some  patient  called  in  for  the  occasion. 

IMPORTANCE   OF   THE  ADMISSION   DESK 

One  of  the  important  stations  in  the  dispensary  is  in 

the  admission  hall,  where  the  patient  visiting  the  dis- 

336 


THE  DISPENSARY 

pensary  for  the  jBrst  time  must  be  met,  have  his  name, 
address,  occupation,  size  of  family,  earnings,  ascer- 
tained and  recorded,  and  be  referred  to  the  proper 
cUnic  for  diagnosis  and  treatment.  The  admission 
desk  is  a  central  point  in  dispensary  administration. 
His  treatment  there  largely  determines  the  patient's 
emotional  tone  in  his  farther  progress  through  the 
waiting  rooms  and  the  clinics,  and  the  attitude  of 
mind  with  which  he  receives  and  interprets  his 
instructions. 

Far  too  little  emphasis  has  been  laid  by  dispensaries 
upon  the  work  at  the  admission  desk.  Too  often  it 
has  been  left  to  a  clerk.  Possibly  some  one  has  been 
engaged  who  can  speak  one  or  more  of  the  prevalent 
foreign  languages,  but  mere  facility  in  language  is  not 
sufficient  to  insure  tactful  and  wise  handling  of  many 
personalities  of  varying  races.  Not  infrequently 
nurses  or  internes  are  detailed  to  admission  service, 
but  for  such  short  periods  that  they  have  no  incentive 
to  acquire  special  competence  for  the  job. 

One  of  the  first  needs  of  the  dispensary,  and  one 
which  has  been  rarely  met,  is  the  employment  of 
skilled,  permanent  service  at  the  admission  desk. 
The  employee  should  have  received,  or  should  be 
given  opportunity  to  acquire,  the  special  training 
necessary  for  really  efficient  performance  of  this  work. 
Knowledge  of  the  language,  while  a  great  convenience, 
is  not  so  essential  as  knowledge  of  the  backgrounds 
and  characteristics  of  the  people.  In  a  dispensary  an 
interpreter  can  almost  always  be  secured  in  an  emer- 
gency. It  is  impracticable  to  have  paid  interpreters 
sufficient  to  cover  all  the  different  languages  found 
among  patients  in  the  average  dispensary,  but  em- 

337 


IMMIGRANT  HEALTH  AND  COMMUNITY 

ployees  speaking  the  more  common  languages  should 
be  found. 

The  conditions  relating  to  the  acquirement  of  for- 
eign languages  by  visiting  nurses  and  other  field 
workers  apply  with  equal  force  to  social  workers  in 
a  dispensary,  particularly  to  those  at  the  admission 
desk.  As  much  knowledge  of  languages  as  is  necessary 
to  make  a  psychologically  pleasant  approach  to  each 
patient  is  invaluable  at  the  admission  desk,  and  some 
degree  of  this  facility  should  be  expected  of  any  per- 
son regularly  employed  there. 

SOCIAL-SERVICE  DEPARTMENT 

The  most  important  step  which  a  dispensary  can  take 
to  adapt  its  internal  administration  to  the  needs  of 
the  immigrant  is  to  organize  a  strong  social-service 
department.  The  admission  of  new  patients  should 
be  in  the  charge  of  this  department;  the  worker  or 
workers  at  the  admission  desk  should  hold  permanent 
positions  there,  and  be  especially  qualified  to  deal 
with  the  races  and  types  of  people  who  come  fre- 
quently to  the  dispensary. 

In  the  dispensary,  as  well  as  in  the  hospital,  the 
social-service  department  has  a  double  function.  In 
the  first  place,  it  is  the  agent  dealing  with  patients 
who  are  under  the  doctor's  care,  assisting  the  physi- 
cian in  controlling  the  patient's  personality  and  en- 
vironment, so  that  medical  treatment  can  be  success- 
fully carried  out.  But  social  service  is  also  an  ad- 
ministrative arm  of  the  dispensary.  The  social 
worker  is  of  value  at  the  admission  desk  and  in  the 

dispensary  clinic  itself,  because  she  is  trained  to  study 

338 


THE  DISPENSARY 

people  and  deal  with  them  on  co-operative  htiman 
terms.  In  this  respect  the  spirit  of  the  social-service 
department  tends  to  be  a  useful  counterbalance  to 
the  highly  specialized  professional  activity  of  the 
medical  staff  itself.^ 


VALUE  OF  FOOD   CLINIC 

A  food  clinic  is  a  valuable  adjunct  to  a  dispensary, 
since  here,  as  in  the  hospital,  dietary  problems  are  a 
significant  element  in  the  treatment  of  disease.  A 
well-trained  dietitian  can  advise  and  instruct  patients 
in  the  selection,  purchase,  and  preparation  of  foods. 
She  can  work  out  family  budgets  and  adapt  a  medi- 
cally prescribed  diet  to  the  patient's  previous  food 
habits  and  the  financial  means  available.  Such  a 
food  clinic  must  take  into  account  the  accustomed 
foods  of  the  foreign  born.  If  this  is  well  done  the  food 
clinic  not  only  furthers  the  medical  treatment  of 
patients,  but  is  an  invaluable  aid  in  winning  their 
imderstanding  and  confidence. 

FOREIGN-BORN  PERSONNEL 

The  presence  on  dispensary  staffs  of  foreign-bom  or 
foreign-speaking  doctors  is  advisable,  whenever  it  is 
possible  to  use  such  physicians  without  lowering  medi- 
cal standards.  Many  notable  examples  of  invaluable 
service  rendered  by  such  physicians  can  be  found, 
both  in  large,  central  dispensaries  and  m  local  clinics. 
Mention  has  been  made  of  a  certain  lack  of  sympathy 

1  Bertha  C.  Lovell,  "Social  Worker  as  Clinic  Executive,"  Modem 
Hospital,  August,  1919,  vol.  xiii,  no.  12,  pp.  153-155. 

339 


IMMIGRANT  HEALTH  AND  COMMUNITY 

shown  by  the  foreign-born  visiting  nurse  for  people 
of  her  own  country.  The  foreign  doctor  in  the  dis- 
pensary cHnic  has  sometimes  shown  the  same  charac- 
teristic. This  is  a  problem  of  personality.  To  secure 
just  any  foreign-speaking  doctor  is  not  enough.  He 
must  be  a  competent,  worth-while  foreign-speaking 
doctor,  concerned  with  assisting  his  people. 

A  large  clinic  needs  a  considerable  administrative 
staff:  a  clinic  secretary,  a  clerk,  a  nurse,  a  social 
worker — one  or  more  of  each.  Where  a  number  of 
people  must  be  employed,  careful  planning  and  selec- 
tion can  get  together  a  staff  who,  between  them,  have 
a  knowledge  of  the  languages  and,  what  is  even  more 
important,  an  understanding  of  the  backgrounds  and 
characteristics  of  the  immigrants  chiefly  encountered. 
Under  a  well-trained,  wise  clinic  executive,  a  young 
woman  of  foreign  parentage  speaking  one  or  more 
European  tongues  may  be  extremely  valuable  as  a 
clerk  and  interpreter,  her  deficiencies  of  judgment 
about  people  and  situations  being  balanced  by  her 
superior  ability  in  communication.  The  selection  and 
balancing  of  the  staff  of  such  a  clinic  is  a  problem  for 
the  superintendent  or  administrator,  who  should  hold 
in  mind  both  the  purpose  of  adapting  the  clinic  to 
the  needs  of  the  people  and  the  necessity  of  under- 
standing the  people  as  a  basis  of  such  adaptation. 

NEED   FOR  LOCALIZATION 

One  of  the  things  which  we  have  found  to  militate 
against  the  use  of  dispensaries  by  immigrants  is  dis- 
tance away  from  the  home  neighborhood.    To  reach 

the  p'eople,  and  particularly  to  overcome  the  obstacles 

340 


THE  DISPENSARY 

presented  by  lack  of  education  and  unfamiliarity  with 
the  American  environment,  the  dispensary  must  be 
brought  to  the  people,  and  not  wait  for  them  to  come 
to  it. 

This  principle  has  been  recognized  by  the  public- 
health  dispensaries.  They  have  not  been  institu- 
tional. They  have  done  what  the  advertising  men 
call  "going  out  after  the  business."  The  establish- 
ment of  a  chain  of  clinics  or  of  infant-welfare  sta- 
tions in  neighborhoods  which  particularly  need  their 
services,  is  characteristic  of  recent  public-health  en- 
deavors. 

The  mere  localization  of  a  clinic,  rendering  the 
building,  and  at  least  some  of  the  workers  in  it,  famil- 
iar by  sight  to  the  neighborhood,  and  the  neighborhood 
familiar  to  the  workers,  is  a  long  step  in  adapting  the 
institution  to  its  clientele.  The  dispensary  must  com- 
pete with  such  commercial  medical  resources  as  the 
quack  and  the  drug  store.  Localization  removes  one 
of  the  disadvantages  under  which  the  dispensary 
otherwise  labors  in  a  competition  wherein  the  aggres- 
sive party  has  the  advantage.  If  the  principles  of 
adaptation  of  the  dispensary  to  the  immigrant  were 
to  be  listed,  that  of  localization  should  have  first 
place. 

In  the  metropolis,  or  even  in  the  city  of  moderate 
size,  a  local  clinic  or  health  center  can  serve  only  a 
small  area.  Therefore,  there  should  be  a  number  of 
such  clinics,  each  with  a  definite  district.  Large  dis- 
pensaries or  out-patient  departments,  however,  must 
be  located  at  central  points  in  a  city,  or  where  trans- 
portation lines  furnish  ready  access,  and  in  each  com- 
munity there  cannot  be  very  many  such  large  dis- 
23  341 


IMMIGRANT  HEALTH  AND  COMMUNITY 

pensaries  fully  equipped  with  every  modern  resource 
for  scientific  work  in  medicine.  How  shall  the  large 
central  dispensary,  which  necessarily  draws  from  a 
wide  area  and  cannot  be  familiar  to  many  persons  as 
a  neighborhood  agency,  overcome  the  disadvantage 
of  distance  from  many  who  need  its  services? 

COMMUNITY  PLAN  FOR  MEDICAL   SERVICE 

The  answer  to  this  question  can  be  found  only  in  a 
community  plan  for  medical  service.  So  long  as  each 
dispensary  is  planned,  located,  and  administered  as  a 
wholly  independent  agency,  the  best  adaptation  of 
the  large  dispensary  to  the  needs  of  special  localities, 
and  particularly  of  immigrant  localities,  presents 
almost  insoluble  problems.  The  local  dispensaries  or 
health  centers  should  be  interrelated  both  as  to  staff 
and  as  to  administrative  methods.  These  should  refer 
patients  needing  treatment  requiring  the  facilities  of 
a  large  institution,  to  the  central  dispensaries.  They 
will  then  build  a  bridge  between  the  neighborhood 
and  the  big,  central  institution. 

The  important  thing  to  remember  is  that  the  ob- 
stacles are  not  so  much  material  as  psychic.  Experi- 
ence has  proved  that  distance  alone  is  a  slight  deter- 
rent when  patients  know  the  institution  to  which  they 
are  to  go,  and  are  confident  of  securing  there  a  greatly 
needed  service.  It  is  the  fear  of  the  unfamiliar,  the 
rumor  that  strange  doctors  will  practice  on  them, 
that  stand  in  the  way. 

The  local  dispensary,  with  its  familiar  quarters  and 
visiting  nurses,  is  the  best  means  of  acquainting  the 
immigrant  with  the  organized  medical  resources  of  his 

342 


THE  DISPENSARY 

new  country.  The  success  of  the  large  central  dis- 
pensaries in  reaching  the  newer  immigrants,  many  of 
whom  are  particularly  in  need  of  their  services,  must 
rest  largely  upon  the  existence  in  the  community  of 
an  adequate  number  of  local  clinics  or  health  centers, 
properly  co-ordinated  one  with  another  and  with  the 
central  medical  resources. 

CO-OPERATION  OF  IMMIGRANTS 

The  dispensary  is  in  a  favorable  position  to  secure  the 
co-operation  of  the  immigrants  themselves,  their  lead- 
ers and  organizations.  Some  dispensaries  build  up  a 
list  of  those  whom  they  call  the  "grateful  patients" 
(G.  P.)  or  "pleased  patients,"  indexed  by  locality, 
nationality,  language,  and  in  various  other  ways,  so 
that  they  can  be  called  on  at  need  for  friendly  service, 
as  interpreters  or  to  persuade  patients  to  carry  out 
medical  treatment.  Here  again  the  social-service  de- 
partment should  be  the  agent  of  the  dispensary  in 
making  this  idea  effective.  The  local  clinic  or  health 
center  finds  it  comparatively  easy  to  build  up  co- 
operation with  neighbors  or  neighborhood  organiza- 
tions. Here,  as  elsewhere,  the  prerequisite  is  the 
right  point  of  view  on  the  part  of  the  superintendent 
and  managers  of  the  dispensary,  a  point  of  view  based 
on  knowledge  of  the  backgrounds  and  characteristics 
of  the  people  with  whom  the  dispensary  deals,  and 
filled  with  sympathy  alike  for  their  qualities,  their 
deficiencies,  their  needs,  and  their  achievements. 


XVI 

INDUSTRIAL  HEALTH  WORK 

While  most  manufacturers  are  probably  conscious 
that  they  employ  numbers  of  immigrants,  a  few  figures 
may  emphasize  the  importance  of  giving  special  con- 
sideration to  this  group  in  industry.  In  1908-09  the 
United  States  Immigration  Commission  made  an  in- 
vestigation of  immigrants  in  industries,  which  was 
summarized  by  Jenks  and  Lauck.^ 

The  proportions  of  foreign  born  among  the  operating 
forces  of  the  principal  branches  of  manufacturing  and 
mining  were  as  follows: 

More  than  half  of  the  iron  and  steel  workers, 

employees  of  oil  refineries, 

slaughtering  and  meat-packing  establishments, 

furniture  factories, 

leather  tanneries  and  finishing  establishments, 

woolen  and  worsted  goods,  and 

cotton-mill  operatives; 
about  two  fifths  of  the  glass  workers; 
one  third  of  the  silk-mill  operatives, 

glove-factory  employees,  and 

cigar  and  tobacco  makers; 
seven  tenths  of  men  and  women  garment  makers; 
more  than  one  fourth  of  the  boot-  and  shoe -factory 

operatives; 
four  fifths  of  the  wage  earners  in  sugar  refineries. 

^  Jenks  and  Lauck,  The  Immigration  Problem  (1913  edition), 
pp.  148-149. 

344 


INDUSTRIAL  HEALTH  WORK 

Does  the  immigrant  employee,  because  of  his  for- 
eign birth,  present  special  medical,  sanitary,  and  health 
problems  to  the  industrial  physician?  If  so,  what 
methods  of  solving  these  problems  are  being  tried  out, 
and  with  what  success?  What  should  be  the  inter- 
relation of  industrial  medicine  and  the  general  medical 
service  of  the  community? 

As  in  other  branches  of  this  study,  information  was 
secured  partly  by  questionnaires  and  partly  by  per- 
sonal visits  and  interviews.  Health  conditions  and 
problems  vary  w4th  the  location  of  an  industry,  with 
its  character,  and  with  the  racial  elements  of  its 
employees.  Consequently,  manufacturing  establish- 
ments in  large  cities  and  in  small  towns,  mining  com- 
munities in  several  parts  of  the  United  States,  and 
finally  some  mercantile  establishments,  were  visited. 
The  Atlantic  coast  states,  the  regions  around  Cleve- 
land and  Chicago,  parts  of  Pennsylvania,  Minnesota, 
Michigan,  Colorado,  and  California,  were  included. 
About  fifty  different  establishments  were  visited,  five 
or  six  people  usually  being  interviewed  at  each.  The 
industrial  physicians,  the  nurses,  the  safety  and  sani- 
tation departments,  and  the  employment  managers, 
were  the  persons  sought  for. 

To  get  the  industrial  physician's  own  conception  of 
what  problems  the  immigrant  brings  to  him,  the 
questionnaire  method  was  first  used.  We  find  in  the 
replies  expressions  of  every  point  of  view,  from  the 
big-stick  theory  up.    One  doctor  writes: 

There  is  an  endless  field  for  doing  good,  and  we  are 
desirous  of  doing  our  part,  especially  teaching  these  men 
of  foreign  birth  to  respect  and  honor  their  adopted 
country.     Teach  them  how  to  live  in  their  homes,  and 

345 


IMMIGRANT  HEALTH  AND   COMMUNITY 

make  them  desirable  citizens,  proud  to  live  [in  the  United 
States]. 

A   contrast   to   this   paternalistic    approach   is   the 
following: 

Give  them  a  square  deal,  house  them  in  habitations  fit 
for  humans  rather  than  in  hovels  and  rabbit  warrens,  ap- 
peal to  them  by  means  of  pictures,  talks  in  their  own 
language,  and  an  honest  desire  to  help  them,  rather  than, 
as  has  been  done,  work  them  to  death,  pay  as  poor  a  wage 
as  possible  to  compel  them  to  accept.  .  .  .  This  is  my 
idea  of  .  .  .  what  might  be  done  to  make  them  better 
physically,  mentally.  We  must  meet  them  on  the  level, 
and  not  condescend  from  a  superior  height. 

The  doctor  who  would  force  the  immigrant  to  con- 
form to  our  standards  is  well  represented  in  the  ques- 
tionnaires. One  physician  suggests  that  we  "  eliminate 
as  far  as  possible  all  foreign  institutions,"  in  the  same 
breath  that  he  advises  the  "abolition  of  the  saloon." 
Another  doctor  feels  the  great  need  for  "education  of 
the  employer  "  if  these  problems  are  to  be  solved.  He 
is  seconded  by  one  who  writes  that  both  "employer 
and  employee  must  be  educated,  the  former  to  spend 
money  for  a  first-class  (welfare)  organization,  and  the 
other  to  accept  graciously  that  which  makes  him  or 
her  a  more  valuable  worker." 

The  following  anecdote  illustrates  better  than  any- 
thing else  an  all  too  prevalent  attitude  toward  the 
immigrant  employee. 

While  I  was  talking  with  one  of  the  nurses  a  Hungarian, 
small  and  dirty,  violently  gesticulating  and  speaking 
broken  English,  came  bursting  into  the  room  next  ours. 
The  employment  manager  stepped  in  from  the  next  room 
to  try  to  quell  the  disturbance.  When  I  passed  through, 
the  nurses  and  the  employment  manager  were  standing  in 

346 


INDUSTRIAL  HEALTH  WORK 

great  annoyance,  laughing  at  this  little  man^  He  was^o 
frantically  eager  to  make  them  miderstand  his  trouwe 
tW  he  was  weeping  at  his  inability  to  do  so,  while  they 
merely  grLId  at  him.    The  employment  manager  ex- 

'''"Oh  tha't  mantwife  is  sick  and  he  wants  us  to  pay  the 
„>ea?  bll"  Then  he  laughed.  How  -ny  farts^J^^^ 
behind  that  statement  it  is  hard  to  say,  nor  was  any  smeere 

attempt  made  to  find  out  from  the  '---'^'^^^'^^^ZZ 
of  his  distress.  He  went  out.  f  t"rn"ig  m  a  few  mome^^^^^^^ 
still  shaken  by  his  excitement,  to  find  the  door  orderea 
locked  against  his  re-entry. 

The  industrial  physician  needs  more  than  medical 
knowledge  to  deal  with  the  problems  P^^^^^d  by 
the  immigrants  in  industry.    It  is  difficult  for  him  to 
feel  anything  but  exasperation  at  the  personal  un- 
cleanliness  of  an  immigrant  employee.    Does  he,  how- 
ever, know  what  the  race  habits  of  this  people  were 
with  regard  to  bathing,  or  what  bathing  facilities  this 
particular  man  now  has  in  his  American  tome?    To 
accomplish  the  best  results  in  preventmg  accidents, 
curLg  disease,  and  promoting  health  and  efficiency 
among  foreign-bom  employees  requires  both  a  con- 
fess of  immigrant  backgrounds  and  a  knowledge 
of  the  conditions  under  which  immigrants  live  m  this 

^'The'^deal  attitude  of  industry  toward  this  question 
appears  in  the  following  quotation:^    "The  manner 
nf  the  future  .  .  .  will  love  men,  and  will  work  with 
Im  to  ml  them  better  men.    He  wiU  study  men 
for  in  the  last  analysis  men  are,  and  always  will  be, 
the  foundation  of  industry  and  civihzation.  .  .  . 
TH^les  E.  Knoeppel,  "Industrial  Organization  as  It  Affects 
Ex^t"  e   and  Workers."    Address  before  the  American  Soc.ety 
of Tiechanical  Engineers,  New  York  C.ty,  December,  1918. 

347 


IMMIGRANT  HEALTH  AND  COMMUNITY 

The  industrial  physicians  were  asked  to  mention 

the  outstanding  problems  in  connection  with  their 

work  with  immigrants.     The  answers  are  indicated 

below: 

TABLE  XXXII 

Outstanding  Problems  of  the  Foreign  Born  in  Industry 
Mentioned  by  Seventy  Industrial  Physicians 


Pboblems 


Housing  conditions 

Kinds  and  preparation  of  food 

Personal  hygiene 

Tuberculosis 

Alcohol 

Occupational  diseases  (chiefly  lead  poisoning).. 

Teaching  English  language 

Trachoma 

Bad  teeth 

Extension  of  medical  service  to  homes 

Venereal  disease 

Hernia 


Times  Mentioned 


22 
12 
10 
7 
6 
6 
6 
4 


It  is  evident  that  many  of  the  "problems"  men- 
tioned in  the  questionnaires  are  common  to  all  em- 
ployees of  industry,  native  and  foreign  born.  But  as 
we  have  seen,  the  immigrants'  problem  is  complicated 
by  unfamiliarity  with  language  and  American  condi- 
tions, and  by  habits  of  life  derived  from  an  entirely 
different  environment. 

The  problems  listed  above  group  themselves  roughly 
into  two  classes,  those  that  can  be  taken  care  of 
within  the  factory  walls,  and  those  that  extend  indus- 
trial medical  work  into  the  homes  of  the  employees 
and  the  community.  The  former  includes  medical 
examination,  emergency  work,  care  of  occupational 
as  well  as  general  diseases,  personal  hygiene  as  well 
as  plant  sanitation.    The  broader  problems  of  housing, 

348 


INDUSTRIAL  HEALTH  WORK 

family  care,  and  public-health  work  in  the  community 
fall  in  the  second  group  and  represent  an  extension  of 
industrial  health  work  already  undertaken  in  many 
places. 

MEDICAL    SERVICE   IN    INDUSTRIAL    ESTABLISHMENTS 

Most  industrial  clinics  originated  as  a  result  of  acci- 
dent compensation  laws.  In  the  first  stage  of  develop- 
ment a  first-aid  kit  was  kept  in  the  building  and  doc- 
tors were  engaged  to  answer  emergency  calls.  The 
next  step  was  the  installation  of  first-aid  stations 
within  the  plant  itself,  with  a  nurse  employed  full 
time;  a  surgeon  was  still  on  call  for  serious  accidents. 
Selby,  in  his  study  of  181  plants  with  clinics,^  found 
that  14  per  cent  had  what  he  called  "detached  emer- 
gency service" — that  is,  doctors  were  summoned  only 
in  case  of  accident.  Then  began  the  physical  exami- 
nation of  applicants  for  work,  and  the  periodic  re- 
examination of  those  exposed  to  industrial  health 
hazards.  From  this  it  was  not  a  far  step  to  the  full- 
time  employment  of  physicians  as  well  as  nurses. 
Selby  found  that  65  per  cent  of  the  362  doctors  in  the 
plants  he  visited  were  full-time  men. 

Following  this,  the  scope  of  the  work  has  broadened. 
Medical  staffs  have  been  enlarged  to  include  oculists 
and  dentists.  Special  medical  equipment  is  often 
provided.  Service  is  extended  to  the  homes.  Educa- 
tional literature  and  health  talks  are  part  of  the 
activities  of  a  few  departments.  Everywhere  there  is 
evidence  of  the  emphasis  put  on  preventive  medicine. 
This  expansion  of  industrial  medical  work  is  ably 

^  C.  D.  Selby,  Studies  of  the  Medical  and  Surgical  Care  of  Industrial 
Workers,  United  States  Department  of  Labor,  1918. 

349 


IMMIGRANT  HEALTH  AND  COMMUNITY 

brought  out  by  Dr.  Harry  E.  Mock,  in  the  Journal  of 
Industrial  Hygiene  for  May,  1919. 

In  this  field,  what  recognition  has  there  been  of  the 
special  problems  of  the  immigrant  employee,  and  what 
has  been  done  to  meet  them?  The  best  way  to  dis- 
cover this  is  to  follow  an  individual  immigrant  through 
a  typical  industrial  clinic.  His  first  point  of  contact 
is  the  man  at  the  desk  in  the  employment  office.  If 
our  applicant  understands  any  English  he  will  get  by 
there  somehow.  If  not,  some  friend  or  neighbor  may 
help  out,  or  he  will  have  to  talk  as  best  he  can  by 
signs.  In  one  particular  factory,  which  we  are  taking 
as  our  example,  he  is  then  sent  to  the  clinic  for  physical 
examination  before  being  placed  at  a  job.  Here  his 
troubles  increase.  He  is  stripped,  without  knowing 
why  in  many  cases,  because  he  can't  understand  what 
is  being  said.    Then  the  doctor  makes  his  examination. 

How  can  an  English-speaking  physician  hope  to  get 
a  personal  history  from  an  immigrant  who  understands 
at  best  only  a  little  English,  and  speaks  imperfectly? 
How  can  the  doctor  explain  to  such  a  man  the  neces- 
sity of  remedying  his  physical  defects  so  that  he  may 
become  a  more  efficient  workman  for  the  company 
which  is  going  to  employ  him?  If  the  employee  knows 
a  little  English  he  may  catch  the  words  "  operation," 
"  cut, "  or '  *  hospital, "  and  at  once  terror  may  fill  his  soul . 

The  new  employee's  job  may  expose  him  to  the 
hazards  of  industrial  disease.  Poisons,  protection  from 
which  requires  careful  personal  habits  and  cleanliness, 
are  a  greater  hazard  to  such  a  workman  than  to  the 
native  born.  The  situation  must  be  carefully  ex- 
plained. Here  again  the  barrier  of  language  is  a  handi- 
cap.    To  make  clear  the  danger  of  something  the 

350 


INDUSTRIAL  HEALTH  WORK 

workman  cannot  see,  such  as  wood-alcohol  vapors,  is 
difficult  if  he  cannot  understand  the  language  of  the 

instructor. 

An  interpreter  who  is  familiar  with  medical  and 
social  work,  and  who  also  understands  the  racial 
heritage  of  the  man  concerned,  is  needed.  To  work 
through  a  third  person  is  clumsy  at  best;  but  it  is 
infinitely  better  to  use  a  trained  interpreter  than  any 
untrained  person  who  happens  along. 

It  is  not  unlikely  that  the  man  we  have  been  follow- 
ing through  a  clinic  is  very  dirty.    The  doctor's  first 
and  peremptory  orders  are  to  take  a  bath— not  once, 
but  frequently.    Then  he  cannot  understand  why  his 
orders  are  not  carried  out.    The  suggestion  of  frequent 
bathing  is  not  such  a  great  shock  to  a  native  American. 
He  at  least  knows  our  bathing  customs  and  is  f  amihar 
with  city  water  supplies  and  bathtubs.    But  to  the 
newly  arrived  immigrant  such  a  suggestion  may  mdi- 
cate  lunacy  or  evil  intent.    Roberts  i  has  cited  some 
vivid  examples,  of  which  the  following  is  one,  of  the 
attitude    some    immigrants    have    toward    frequent 
bathing: 

A  young  Pole  was  induced  to  go  into  the  swimming  pool 
in  a  Younc^  Men's  Christian  Association;  after  that  he  kept 
away  from  the  building,  and  the  secretary  went  to  find  out 
why  he  stayed  away.  The  mother  of  the  lad  met  him, 
gave  him  a  piece  of  her  mind,  that  he  dared  make  her  boy 
take  a  bath  in  winter  time.  "  Did  you  want  to  kill  hun. 
Thousands  of  immigrants  from  southeastern  Europe  do  not 
appreciate  the  value  of  personal  cleanlmess. 

One  important  way  in  which  the  industrial  physician 
can  aid  his  employer  to  reduce  disease  and  accident,  is 

I  Peter  Roberts,  The  New  Immigration,  1914,  p.  134. 

351 


IMMIGRANT  HEALTH  AND   COMMUNITY 

to  enter  the  mother  tongue  and  nationahty  of  every 
man  examined  on  his  medical  records,  and  then  analyze 
statistics  by  race.  The  making  of  the  original  entry 
may  be  the  duty  of  the  employment  department,  but  the 
medical  department  should  know  and  utilize  the  facts. 

So  few  industrial  clinics  do  this  that  the  point  can- 
not be  too  strongly  stressed.  Our  investigation  re- 
vealed that  many  nurses  had  no  knowledge  of  the 
races  in  their  plant,  the  number  of  employees  of  each, 
nor  of  diseases  or  accidents  by  races.  They  did  not 
even  know  that  there  was  a  place  on  their  medical 
record  for  a  nationality  entry. 

A  few  doctors  have  carried  out  this  idea  with  great 
advantage,  not  only  to  the  company  employing  them, 
but  to  others  having  to  meet  the  same  problems.  One 
of  these  men  found  by  analyzing  his  records  that  hernia 
occurred  more  commonly  among  the  southeastern 
European  employees,  Italians  in  particular,  than 
among  other  races  doing  the  same  kind  of  work.  His 
next  step  in  regard  to  this  observation  will  probably 
be  a  study  of  food  habits  among  the  Italian  employees. 
This  same  doctor  has  noted  more  pernicious  anaemia 
among  Swedes  than  among  the  southern  European 
races.  So  he  will  go  on  analyzing  the  data  secured  day 
by  day  in  the  routine  work  of  the  clinic,  and  applying 
the  knowledge  gained  to  the  practical  demands  of  his 
industry.  There  is  a  great  need  for  more  extended 
study  of  this  kind  to  provide  a  sound  statistical  basis 
for  work  with  foreign-born  employees. 

ACCIDENT   PREVENTION 

Education  of  employees  to  prevent  accidents  and  in- 
dustrial diseases  has  received  a  great  deal  of  attention 

352 


INDUSTRIAL  HEALTH  WORK 

since  workmen's  compensation  laws  began  to  be 
enacted  nine  years  ago.  The  National  Safety  Council 
is  an  outgrowth  of  this  movement.  Yet  far  too  little 
importance  has  been  attached  to  the  human  element 
in  industrial  accidents,  the  mechanical  elements  re- 
ceiving first  attention.  In  recent  years,  however, 
safety  engineers  and  plant  managers  have  recognized 
the  human  factors  much  more  fully  than  formerly, 
and  the  foreign-born  employee  is  beginning  to  receive 
attention. 

Safety  department  heads  usually  speak  as  if  all 
workmen  had  a  common  background  of  habits  and 
tradition  on  which  to  base  educational  work  for  acci- 
dent prevention,  and  as  if  all  could  read  and  write  the 
English  language.  On  the  contrary,  the  foreign-born 
employee  is  not  infrequently  a  special  accident  hazard, 
to  himself,  his  fellow  workers,  and  his  employer. 

The  great  majority  of  the  recent  immigrants  have 
come  from  the  peasantry  of  Europe  and  know  nothmg 
of  industrial  conditions  and  demands.  Of  181,330 
male  employees  from  whom  information  was  secured 
by  the  United  States  Immigration  Commission,  only 
15.3  per  cent  had  been  employed  in  manufacturing 
before  coming  to  the  United  States;  10.3  per  cent  had 
been  general  laborers;  and  53.9  per  cent  had  been 
farmers  or  farm  laborers.^  These  facts,  combined  with 
the  fact  that  it  is  several  years  before  the  immigrant 
learns  to  speak  English,  make  him  a  special  accident 
problem. 

The  more  progressive  among  employers  to-day 
recognize  this  factor.    According  to  the  Semet-Solvay 

iJenks  and  Lauck,   The  Immigration  Problem,  fourth  edition, 

1913,  p.  493. 

353 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Company  of  Detroit,^  "there  are  thousands  paid  out 
for  injuries,  many  of  which  may  be  traced  directly  to 
the  inability  of  the  employee  to  understand  English.'* 
Clarence  H.  Howard,  president  of  the  Commonwealth 
Steel  Company,  St.  Louis,  says:^  "Records  kept  in 
our  industry  show  that  80  per  cent  of  the  injuries  re- 
ceived by  our  workmen  were  among  the  non-English- 
speaking  employees,  though  they  constitute  only  34 
per  cent  of  the  force."  Henry  Ford's  testimony  is 
that  ^  "  accidents  in  the  plant  have  been  decreased 
54  per  cent  as  employees  are  able  to  read  factory 
notices  and  understand  instructions." 

There  are  other  ways  besides  teaching  English  to 
reach  the  immigrant  employee  in  accident-prevention 
work.  The  usual  method  of  breaking  in  a  new  work- 
man to  a  hazardous  job  is  to  turn  him  over  to  the 
mercies  of  a  busy  foreman,  who  is  pretty  sure  to  speak 
English  only,  though  he  may  know  a  few  foreign 
phrases.  This  man  is  generally  regarded  by  the  man- 
ager as  ne  'plus  ultra  at  this  work,  and  to  him  is  most 
often  intrusted  the  training  of  the  worker  ignorant  of 
American  machinery,  of  health  hazards  in  industry, 
and  of  the  very  language  in  which  his  instruction  is 
given .  The  *  *  dumb ' '  and  confused  immigrant  will  nod 
his  head,  indicating  that  he  understands  what  really 
has  been  Greek  to  him.  Such  methods  as  these  result 
in  large  accident  rates  and  perhaps  numerous  cases  of 
industrial  disease  in  places  where  immigrants  are 
employed. 

The  shop  organization  should  make  provision  for 

^  What  Industrial  Leaders  Say  About  Americanization.  Leaflet 
of  the  Chamber  of  Commerce  of  the  United  States  of  America, 
1918,  pp.  8,  10.  2  76^.  3  /^'d, 

354 


INDUSTRIAL  HEALTH  WORK 

explaining  the  hazards  of  his  job  to  the  non-English- 
speaking  workman  in  his  own  tongue.  Foreign  em- 
ployees who  have  been  through  the  breaking-in  process 
might  well  be  placed  on  a  shop  committee  to  handle 
this  matter,  under  the  direction  of  a  central  "safety 
department."  The  haphazard  methods  of  the  past 
must  give  way  to  an  intelligently  planned  and  organ- 
ized system  for  instructing  the  immigrant  employee. 

One  concern  claims  to  have  developed  a  method  of 
using  their  foremen  in  this  connection  with  satisfactory 
results.^ 

An  interesting  innovation  is  in  operation  at  the  Amoskeag 
Manufacturing  Company  plant  to  reduce  accidents  at 
especially  hazardous  work.  The  overseer  or  foreman  is 
required  to  fill  in,  sign,  and  file  with  the  employment 
department  a  certificate  stating  that  he  personally  provided 
a  suitable  and  safe  place  in  which  to  work,  inspected  the 
machinery  and  apparatus  to  be  used,  and  found  them  safe 
and  suitable  for  the  work  in  hand,  explained  the  company's 
rules  and  regulations  for  employees  engaged  in  such  work, 
ga.ve  express  orders  never  to  clean  gears,  belts,  or  moving 
parts  of  machines  while  in  motion,  and  acquainted  the 
fellow  workman  selected  to  teach  the  new  employee  with 
the  latter's  inexperience,  and  instructed  him  to  point  out 
the  dangers  incident  to  such  work.  Special  care  is  taken 
to  give  such  instruction  in  the  new  employee's  own  language 
— if  necessary  through  an  interpreter,  whose  name  must  be 
given. 

Posters  and  leaflets  in  foreign  languages  will  be  of 
service  when  the  employee  is  literate  in  his  own  tongue. 
It  must  not  be  forgotten,  however,  that  of  the  immi- 
grants from  southeastern  Europe  fourteen  years  of 

1  Bulletin  No.  3,  Chamber  of  Commerce  of  the  United  States  of 
America,  Jime  1,  1916,  p.  2. 

355 


IMMIGRANT  HEALTH  AND  COMMUNITY 

age  and  over,  admitted  to  the  United  States  from 
1897  to  1917,  33  per  cent  were  illiterate,  and  to  them 
rules  and  regulations  printed  in  their  mother  tongue 
will  do  no  good. 

The  Pennsylvania  Railroad  has  "an  elaborate  sys- 
tem of  pamphlets  for  first-aid  work  and  instruction 
in  English.  The  lessons  in  the  latter  group  are  ex- 
tremely practical,  utilizing  the  mechanical  tasks  of  the 
worker  as  subject  matter.  English  and  the  foreign 
language  are  given  in  parallel  columns,  with  illustra- 
tions showing  proper  and  improper  methods  of  work 
from  the  point  of  view  of  the  safety  of  the  employee."  ^ 
Other  large  firms  may  well  study  these  methods.  This 
same  railroad  has  prepared  a  film  "called  *The  Ameri- 
canization of  Tony,'  which  introduces  'Safety  First,' 
and  emphasizes  the  need  of  Americanization."^  The 
possibilities  of  the  moving  picture  in  this  work  are 
great,  and  as  yet  but  little  developed. 

Methods  used  for  the  promotion  of  safety  work 
apply  equally  well  to  plant  sanitation.  The  educa- 
tional value  of  clean,  modern  toilet  facilities,  in  a  fac- 
tory, cannot  be  overestimated,  but  the  immigrant 
must  be  taught  how  to  use  them.  Many  immigrants 
have  never  in  their  lives  seen  a  water-flushed  toilet 
before  coming  to  this  country. 

Any  campaign,  then,  for  the  prevention  of  accidents 
and  industrial  diseases  and  the  promotion  of  safety 
and  sanitation,  must  take  into  consideration  the  for- 
eign-born employee.     His  background  differs  widely 

1  What  Industrial  Leaders  Say  About  Americanization.  Leaflet 
of  the  Chamber  of  Commerce  of  the  United  States  of  America, 
1918,  p.  9. 

2  Bulletin  No.  23X,  Chamber  of  Commerce  of  the  United  States 
of  America,  June  1,  1918,  p.  3. 

356 


INDUSTRIAL  HEALTH  WORK 

from  that  of  the  native  American  workman;  his  igno- 
rance of  the  EngHsh  language  makes  it  impossible  for 
him  to  understand  the  educational  material  which 
reaches  the  native.  Special  methods  must  be  em- 
ployed in  order  to  achieve  the  best  results. 

BENEFITS   AND    CO-OPERATIVE   PLANS 

A  number  of  schemes  for  insuring  employees  against 
accident  and  sickness  are  operating  in  concerns  having 
many  foreign-born  employees.  Notable  is  that  of  the 
International  Harvester  Companies,  whose  Em- 
ployees' Benefit  Association  dates  from  1908.  Over 
50  per  cent  of  the  employees  are  said  to  be  of  foreign 
birth.  Sick  benefits,  disablement  benefits,  and  death 
benefits  are  provided,  from  a  fund  made  up  of  con- 
tributions from  members  of  about  1.5  per  cent  of  their 
wages,  and  contributions  from  the  companies.  The 
board  of  trustees  is  chosen  half  by  employees  and 
half  by  the  companies.  Medical  care  is  not  furnished. 
The  average  membership  from  the  manufacturing 
plants  during  1917  was  78.4  per  cent,  and  included 
large  numbers  of  foreign-born  employees. 

Even  this  plan,  certainly  one  of  the  most  successful 
of  its  kind,  does  not  assure  competent  medical  service 
at  reasonable  rates.  The  employee  receives  as  sick 
benefit  half  his  usual  weekly  wage,  and  is  required  to 
take  care  of  himself  "and  have  proper  treatment." 
How  to  pay  for  doctors'  fees  and  medicines  in  addition 
to  the  regular  living  expenses  of  the  family,  on  half 
the  usual  income,  must  be  a  hard  nut  to  crack.  Plans 
of  this  type  are  a  definite  help  to  many  families,  but 
do  not  solve  the  problem  of  providing  adequate  medical 
24  257 


IMMIGRANT  HEALTH  AND  COMMUNITY 

care.  Most  of  them  involve  much  less  participation 
by  the  employees  than  does  the  one  described  above. 

There  are  also  plans  for  industrial  medical  service 
initiated  and  controlled  entirely  by  the  workers.  The 
Joint  Board  of  Sanitary  Control,  in  New  York  City, 
furnishes  perhaps  the  most  prominent  example.  This 
is  an  organization  managed  and  supported  by  workers 
in  certain  women's  garment  trades,  and  touching  the 
lives  of  over  75,000  workers  in  more  than  2,700  indus- 
trial establishments.  Through  its  members  the  board 
supervises  conditions  of  safety,  sanitation,  and  general 
conditions  relating  to  health  in  the  clothing  industries 
of  New  York,  which  are  united  under  the  Protocol  of 
Peace.  It  seeks  to  enforce  "standards  not  by  police 
power  or  compulsion,  but  by  education,  co-operation, 
and  educational  persuasion."  ^ 

In  1912  it  established  a  clinic  where  any  worker  in 
the  industry  may  be  examined,  and  which  supervises 
the  sick  benefits  paid  by  the  locals  of  the  union.  The 
unions  also  pay  for  sanatorium  treatment  for  members 
suffering  from  tuberculosis,  and  provide  nose,  throat, 
eye  and  ear,  and  dental  clinics.  "The  main  signifi- 
cance of  these  clinics  lies,  of  course,  in  the  fact  that 
they  are  conducted,  financed,  and  managed  by  the 
workers  themselves,  for  their  own  benefit."  ^  As  large 
numbers  of  the  garment  workers  are  Jews  and  Italians, 
either  foreign  born  or  the  first  generation  here,  it  is 
evident  that  their  organization  is  closely  related  to 
the  problem  of  medical  care  for  the  immigrant.  Only 
a  minority  of  the  members,  however,  appear  to  make 
regular  use  of  their  clinics. 

^  Dr.  George  M.  Price,  Modern  Medicine,  May,  1919,  p.  49. 
^  Ibid.,  p.  50. 

358 


INDUSTRIAL  HEALTH  WORK 

Another  phase  of  industrial  medicine  with  which 
the  industrial  physician  should  be  familiar  is  to  be 
found  in  New  York  City>    This  is  the  relationship 
established  by  the  Department  of  Health  between 
its  Division  of  Industrial  Hygiene  and  the  labor  unions 
in  the  city,  and  known  as  the  Labor  Sanitation  Con- 
ference.   It  is  an  endeavor  to  associate  labor  unions 
and  a  city  department  in  improving  general  health 
conditions  in  the  factories  of  the  city.     Education, 
both  of  employees  and  employers,  is  a  prominent  part 
of  the  work.    The  pohce  power  of  the  city  department 
is  used  when  need  arises,  and  the  75,000  members  of 
the  affiliated  unions  act  as  voluntary  inspectors  for 
the  department.     On  one  occasion  the  department 
conducted  physical  examinations  on  a  voluntary  basis 
for  union  members,  who  were  largely  foreign  born. 

To  be  successful,  such  plans  require  the  voluntary 
co-operation  of  all  workers  concerned,  and  this  in- 
volves an  immense  amount  of  educational  work  with 
the  immigrants.  Most  of  the  foreign  born  are  not  so 
much  interested  in  health  as  they  are  in  personal 
iUness.  Sickness  makes  them  think  of  the  health  they 
have  had,  but  so  long  as  they  are  weU  it  is  very  diffi- 
cult for  them  to  appreciate  the  need  of  preventive 
work,  and  that  is  the  ultimate  interest  of  such  organi- 
zations as  these  in  New  York  City. 

It  should  be  apparent  that  plans  for  co-operative 
medical  service  by  and  for  employees  will  not  super- 
sede the  well-developed  chnic  in  an  industry.  Many 
medical  and  sanitary  problems  are  closely  linked  with 
the  individual  factory  and  can  best  be  dealt  with  from 

iDr.  Louis  I.  Harris,  Monthly  Bulletin  of  the  Department  of 
Health  of  New  York  City,  June,  1917. 

359 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  inside.  The  factory  clinic  should  maintain  super- 
vision of  the  immigrant's  health  and  the  conditions 
under  which  he  works.  It  should  see  directly  or  in- 
directly that  medical  care  for  himself  and  his  family 
is  available  and  within  reach  of  his  pocketbook.  What- 
ever tends  to  keep  workers  well  tends  also  to  stabilize 
labor  conditions.  Good  medical  service  to  employees 
is  also  service  to  the  employer. 

EXTENSION  OF  SERVICE  TO  HOMES 

A  few  industrial  physicians  have  extended  medical 
service  beyond  the  plant  itself  to  the  homes  of  the 
employees.  The  value  of  such  service  to  the  immigrant 
and  his  family  is  great,  especially  if  obstetrical  care 
and  medicines  are  included. 

Not  all  physicians,  however,  agree  to  the  advis- 
ability of  doing  this.  It  is  contrary  to  the  policies  of 
such  representative  plants  as  the  Norton  Company  in 
Worcester  and  the  Goodrich  Company  in  Akron,  Ohio. 
Both  these  plants  are  located  in  cities  large  enough  to 
provide  other  medical  facilities,  and  their  doctors  feel 
that  the  industrial  physician  should  not  infringe  on 
the  practice  of  private  doctors. 

Endicott  Johnson  and  Company,  of  Endicott,  New 
York,  hold  the  opposite  point  of  view.  They  have 
three  nurses  for  visiting  the  homes  of  their  employees 
and  another  three  for  clinic  activities.  Obstetrical 
service,  as  well  as  eye,  ear,  nose,  and  throat  work,  are 
free  to  the  families  of  employees.  Their  visiting  nurses 
make  both  prenatal  and  postpartum  calls. 

Apparently  a  company's  attitude  on  this  question 

is  determined  to  a  large  degree  by  the  size  of  the 

360 


INDUSTRIAL  HEALTH  WORK 

community  in  which  it  is  located,  and  by  the  other 
medical  resources  which  are  available  in  the  vicinity. 
The  boundary  line  of  responsibility  is  a  delicate  and 
changing  one,  and  its  decision  for  any  industrial  estab- 
lishment requires  careful  analysis  of  environment. 

In  most  places  where  the  physicians  employed  by 
industries  are  the  only  ones  available,  it  is  of  utmost 
importance  to  the  immigrant  employee  that  his  fam- 
ily have  access  to  the  doctor's  services.  Moderate 
prices  mean  more  prompt  medical  care,  and  this  in 
turn  means  reduction  in  time  lost  through  illness  of 
the  worker  or  his  family. 

Nursing  aid  extended  to  the  homes  has  great  value 
in  any  locality,  particularly  in  relation  to  the  immi- 
grant. The  visiting  nurse  is  probably  more  welcome 
than  any  other  person  in  the  homes  of  the  foreign 
born,  because  she  comes  on  errands  of  mercy  and 
helpfulness. 

This  is  one  reason  why  it  is  disastrous  for  an  indus- 
try to  use  a  nurse  as  a  truant  officer  in  following  up 
absences  among  the  immigrant  workers.  They  soon 
feel  that  she  to  whom  they  have  turned  as  a  friend  in 
time  of  illness  has  become  a  spy  and  intruder  in  their 
family  life.  The  consequent  resentment  kills  the 
nurse's  opportunity  to  carry  on  educational  work  in 
connection  with  her  friendly  aid. 

Hers  is  the  chance  to  adjust  food  habits  to  the  de- 
mands of  American  life;  to  teach  American  standards 
of  hygiene  and  sanitation  in  both  factory  and  home, 
and  to  spread  knowledge  as  to  the  proper  care  of  the 
children  who  are  to  be  the  workmen  of  to-morrow. 
Only  by  slowly  winning  the  immigrant's  confidence 

and  trust  can  extension  of  medical  service  be  made 

361 


IMMIGRANT  HEAXTH  AND  COMMUNITY 

of  value  to  him  and  to  the  industry  which  employs 
him, 

HOUSING 

Some  industries  have  extended  their  health  work  into 
the  field  of  housing.  The  necessity  for  this,  also, 
varies  largely  with  the  circumstances  in  which  the 
industry  finds  itself.  That  the  housing  of  his  workers 
is  important  to  the  employer  needs  little  proof.  Evi- 
dence from  England  on  this  point  is  brought  by 
Charles  C.  May  in  Modern  Medicine:  ^ 

Given  two  factories  with  identical  conditions  in  aU 
other  respects,  but  one  housing  its  workers  well,  the  other 
permitting  the  old-style  "settlement"  to  exist  ...  it 
needs  no  argument  to  prove  which  of  the  two  factories 
will   have   the   greater   charge   for   labor   turnover.  .  .  • 

TABLE  XXXni 

Comparison  of  the  Weight  and  Height  of  Children  op  Dif- 
ferent Ages,  Living  in  Bourneville  and  Birmingham, 
England 


Weight  in  Pounds 
Boys,  Bourneville 

*'     St.  Bartholomew's  Ward 
Girls,  Bouf neville 

"     St.  Bartholomew's  Ward 
Height  in  Inches 
Boys,  Bourneville 

"     St.  Bartholomew's  Ward . 
Girls,  Bourneville 

"     St.  Bartholomew's  Ward 


Age 


6 

Years 

8 
Years 

10 
Years 

12 

Yeara 

45.0 

52.9 

61.6 

71.8 

39.0 

47.8 

56.1 

63.2 

43.5 

50.3 

62.1 

74.7 

39.4 

45.6 

53.9 

65.7 

44.1 

48.3 

51.9 

54.8 

41.9 

46.2 

49.6 

52.3 

44.2 

48.6 

52.1 

56.0 

41.7 

44.8 

48.1 

53.1 

1  Charles  C.  May,  "Better  Housing,"  Modem  Medicine,  May, 
1919,  p.  70. 

362 


INDUSTRIAL  HEALTH  WORK 

Persuasive  are  the  statistics  ...  of  the  effect  on  boys  and 
girls,  in  weight  and  height,  of  the  conditions  of  a  garden 
town  like  Bourneville,  as  compared  with  Saint  Bartholo- 
mew's Ward,  in  Birmingham,  only  twenty  minutes  away 

Take  these  two  groups  of  bo\'S  and  girls,  one  hundred 
from  the  city  slums,  the  other  hundred  from  the  garden 
town,  and  line  them  up  before  your  industrial  magnate. 
"There  you  are,  sir.  From  which  group  will  you  recruit 
your  shop  forces.^"  Is  there  a  question  as  to  where  his 
choice  will  light.^ 

The  Goodyear  Tire  and  Rubber  Company^  issued 
in  1918  a  booklet  describing  their  building  projects, 
entitled,  "Wliich  Shall  It  Be,  Home  or  Hovel.^ "  Ac- 
cording to  this  circular,  building  of  houses  for  em- 
ployees *'is  not  charity.  It  is  not  graft.  It  is  hu- 
manity; above  all,  good  business.  No  man  worried 
at  home,  living  in  a  hovel  surrounded  by  dirt  and  filth, 
his  family  subjected  to  all  the  dangers  and  disease 
which  infest  such  habitations,  can  do  good  work.'* 

Sometimes  houses  erected  by  an  industry  are  only 
rented  to  its  employees;  sometimes  they  are  sold  to 
workmen  on  the  installment  plan.  More  and  more 
industries  are  buying  land  in  rural  regions  and  building 
their  own  villages  near  by.  Such  houses  built  to-day 
are  equipped  with  modern  conveniences;  made  to 
meet  the  needs  of  various  sized  families,  including 
those  which  take  boarders;  and  often  provide  space 
for  the  little  garden  so  dear  to  the  heart  of  the  immi- 
grant fresh  from  the  fields  of  Europe.  The  importance 
of  this  last  point  is  appreciated  by  one  large  company 
which  is  now  considering  building  for  its  employees.^ 


^  Notes  by  H.  T.  Waller,  Goodrich  Company,  sent  to  W.  M. 
Leiserson,  of  the  Americanization  Study  staff. 

363 


IMMIGRANT  HEALTH  AND  COMMUNITY 

.  .  .  From  our  experience  we  do,  however,  urge  that  any 
plan  of  housing  for  the  immigrant  employee  should  include 
a  lot  of  land  enabling  the  foreign  employee  to  exercise  his 
native  ability  in  market  gardening. 

Homes  built  in  this  way  will  be  powerful  factors  in 
promoting  health  and  in  teaching  the  immigrant 
American  standards  of  sanitation.  Many  of  the  em- 
ployers, who  will  only  rent  their  houses  to  employees, 
say  that  this  policy  is  necessary  to  protect  the  prop- 
erty and  to  maintain  a  good  standard  of  cleanliness. 
Peasants  who  have  been  accustomed  to  the  most 
primitive  housing,  without  running  water  or  toilet 
facilities,  who  have  frequently  lived  in  the  same 
building  with  their  animals,  cannot  be  expected  at 
once  to  accept  or  to  practice  American  methods  of 
keeping  clean. 

A  few  industries  are  doing  educational  work  through 
women  inspectors,  whose  business  it  is  to  inspire  the 
immigrant  with  the  desire  to  imitate  American  stand- 
ards. These  women  work  in  the  homes,  and  in  one 
case  they  also  utilize  a  neighborhood  center  established 
and  supported  by  the  industry  itself.  A  very  good 
example  of  such  a  combined  housing  and  educational 
policy  is  to  be  found  in  Morgan  Park,  Minnesota. 

The  question  of  boarders  seriously  affects  the  hous- 
ing of  foreign-born  employees.  Boarders  and  roomers 
are  usually  taken  for  one  of  two  reasons — economic 
necessity,  or  the  desire  to  help  newly  arrived  com- 
patriots. Industry  has  the  power,  in  a  large  degree, 
to  abolish  the  first  factor.  The  seriousness  of  the 
second  varies  according  to  the  races  employed.  The 
groups  which  average  the  greatest  number  of  boarders 

or  roomers  are  those  among  whom  there  is  a  large 

364 


INDUSTRIAL  HEALTH  WORK 

proportion  of  single  men,  chiefly  the  Croatians,  Lith- 
uanians, MagjT^ars,  Poles,  Serbians,  Rumanians,  and 
Greeks.  In  considering  any  housing  project  for  indus- 
trial workers  the  races  involved  should  be  studied  in 
order  to  adapt  the  plans  as  far  as  possible  to  their 
particular  habits  and  needs. 

FLOATING   LABOR   CAMPS 

Quite  different  from  the  problem  of  housing  factory 
employees  is  that  of  accommodating  floating  labor  in 
camps.  This  type  of  labor  is  usually  associated  with 
such  industries  as  lumbering,  ice  cutting,  beet-sugar 
and  fruit  growing,  or  with  highway  and  railroad  con- 
struction and  repair  work,  and  is  largely  composed  of 
immigrants,  as  is  brought  out  by  Jenks  and  Lauck.* 

Disregarding  geographical  lines,  it  may  be  said,  in 
general,  that  foreign-born  wage  earners  constitute  more 
than  three  fourths  of  the  entire  number  of  persons  engaged 
in  railway  and  other  construction  work. 

In  1912  and  1913  W.  M.  Leiserson  made  a  study  of 
labor  camps  in  Wisconsin  for  the  Industrial  Commis- 
sion of  that  state.^  Of  the  50,000  wage  earners  living 
in  camps  in  W  isconsin,  he  calculated  that  20,000  were 
housed  in  bunk  cars  for  railroad  work;  20,000  in  lum- 
ber camps;  5,000  in  ice-cutters'  camps,  and  5,000  in 
camps  for  the  construction  of  dams,  buildings,  roads, 
and  bridges. 

The  railroad  "gangs"  were  housed  in  box  cars, 
which  allowed  170  cubic  feet  of  air  per  man,  one  haK 

^  Jenks  and  Lauck,  The  Immigration  Problem,  1913,  p.  180. 
2  W.  M,  Leiserson,  Labor  Camps  in  Wisconsin,  Industrial  Com- 
mission of  Wisconsin,  pamphlet,  1913. 

365 


IMMIGRANT  HEALTH  AND  COMMUNITY 

of  tlie  legal  requirement  in  Wisconsin.  The  sanitary- 
conditions  of  the  camps  were  primitive,  and  there  was 
no  provision  for  taking  care  of  the  sick.  Leiserson 
rarely  found  sick  men  in  the  camps  because  they  leave 
as  soon  as  they  become  ill. 

The  housing  conditions  in  the  lumber  camps  were 
generally  worse  than  in  the  railroad  camps.  Two  of 
the  camps  were  found  to  be  better  than  the  rest. 
Running  water,  good  beds,  and  bedding  were  pro- 
vided; there  was  plenty  of  space  allowed  per  man; 
the  buildings  were  light,  airy,  and  clean.  These  camps 
had  no  difficulty  in  holding  men,  and  were,  in  fact, 
turning  away  applicants. 

Another  example  of  suitable  housing  is  that  of  the 
Park  Falls  Lumber  Company  of  Wisconsin.^ 

Each  logging  camp  has  twelve  cars,  of  which  four  are 
used  for  the  horses.  One  is  a  power  car  which  provides 
the  electric  current  for  all  cars  and  pumps  the  drinking 
water  into  an  air  tank,  which  fm-nishes  running  water  in 
the  washing  car  and  kitchen  car.  A  vapor-heating  system 
is  used  and  the  cars  are  comfortable  in  the  coldest  weather. 
Sleeping  cars  are  divided  into  four  rooms,  each  12'xl5'. 
Each  room  has  a  door  and  window,  constructed  opposite 
each  other,  to  provide  proper  ventilation,  and  contains 
six  single-spring  bunks.  A  dining  car,  containing  small 
tables,  seats  114  men.  An  equal  number  of  cars  are 
placed  opposite  each  other,  with  a  platform  in  the  center 
which  is  lighted  at  night,  so  that  the  men  may  pass  from 
car  to  car  without  touching  the  ground.  Camp  and 
commissary  refuse  is  removed  every  morning. 

The  company  found  that  the  original  cost  of  such  equip- 
ment was  double  the  cost  of  a  set  of  ground  camps  to  ac- 
commodate the  same  number  of  men  and  horses,  but  states 


^Bulletin  No.  2,  May  5,  1916,  Chamber  of  Commerce  of  the 
United  States  of  America,  p.  8. 

366 


INDUSTRIAL  HEALTH  WORK 

that  it  has  brought  ample  return  on  the  investment,  as  the 
camp  can  be  moved  from  place  to  place  and  considerable 
time  is  saved  walking  to  and  from  work,  while  the  men 
appreciate  these  conditions  so  much  that  the  company 
has  had  no  trouble  in  retaining  them  since  operations  were 
commenced.  It  is  now  planned  to  add  a  sixty -foot  car  to 
each  camp  fitted  up  as  a  reading  room  and  a  bathroom, 
and  to  replace  all  the  company's  ground  camps  with  this 
type  of  living  quarters. 

The  Commission  of  Immigration  and  Housing  of 
California  has  developed  standards  for  labor  camps 
which  may  serve  in  many  respects  as  models  for  the 
country.  The  problem  in  California  is  peculiar  be- 
cause of  the  climate  and  the  characteristics  of  the 
Mexicans,  who  are  a  predominant  element  in  the  agri- 
cultural sections  of  the  state.  The  Mexican  laborer 
generally  has  his  family  with  him,  and  they  move  as 
a  tmit  from  one  place  to  another.  For  these  workers 
the  commission  has  provided  small  family  houses  and 
supervision  of  sanitary  regulations.  It  has  been 
equally  successful  in  its  work  in  the  mining  and  lum- 
ber regions,  where  the  labor-camp  problems  are  sim- 
ilar to  those  elsewhere  in  the  United  States. 

The  wide  support  which  the  California  commission 
has  received  from  both  employing  and  labor  interests, 
its  nonpolitical  character,  and  its  expert  work  in  the 
field  of  sanitation  and  housing,  render  its  findings  of 
the  first  importance  to  the  problems  of  the  foreign  bom. 

It  is  almost  impossible  to  deal  with  the  problem  of 
floating  labor  by  local  regulation.  The  labor  is  too 
migratory;  the  camp  is  often  temporary,  and  usually 
isolated.  The  state  as  a  whole  must  set  standards 
and  supervise  their  enforcement.  In  some  occupa- 
tions, particularly  railroad  work,  where  the  problem 

367 


IMMIGRANT  HEALTH  AND  COMMUNITY 

is  an  interstate  one,  the  United  States  Public  Health 
Service,  or  some  other  Federal  agency,  may  properly 
intervene  to  prevent  unsanitary  camp  conditions. 

THE  PIONEER  MINING   COMMUNITY 

As  in  the  floating  labor  camps,  conditions  in  isolated 
mining  communities  require  the  employers  to  carry 
health  work  beyond  the  confines  of  the  industry  itself. 
This  is  exemplified  in  the  Mesabi  and  Vermilion  iron 
ranges  of  Minnesota  and  the  copper  range  of  northern 
Michigan.  Seven  mining  towns  in  these  two  ranges 
were  visited  in  the  course  of  this  study  and  many  in- 
terviews were  held  with  persons  engaged  in  and 
affected  by  health  work — doctors,  nurses,  employees, 
and  superintendents. 

When  this  region  was  first  opened,  housing,  water 
supply,  sewage,  garbage,  and  ash  removal,  mainte- 
nance of  streets,  all  were  provided  by  the  companies. 
In  the  iron  ranges  where  open-pit  mining  obtains, 
permanent  dwellings  are  impracticable.  Little  shacks, 
uninviting,  unhealthful,  and  desolate,  are  erected  at 
the  edge  of  the  pits.  The  company  is  unwilling  to 
spend  money  on  buildings  in  a  locality  which  in  a 
brief  interval  will  be  evacuated  for  another  site,  and 
the  workers  cannot  afford  to.  Under  such  conditions 
less  headway  has  been  made  in  the  solution  of  medical 
and  sanitary  problems  than  in  the  copper  ranges. 

The  mines'  mouths  in  the  copper  ranges  are  fixed 

for  years,   and  here  the  companies  provide  better 

houses  and  more  adequate  sanitation.    Overcrowding 

is  evident,  however,  and  public-health  problems  are 

still  far  from  being  solved. 

The  reason  for  this  can  perhaps  be  found  in  the  so- 

368 


INDUSTRIAL  HEALTH  WORK 


TEMPORARY  SHANTIES  MAY  BE  THE  ONLY  HOMES   FOR 
IMiVIIGRANTS  IN  MINING  COMMUNITIES 


called  contract  system  of  industrial  medicine,  used 
widely  on  all  these  ranges.  This  is  said  to  have  been 
imported  with  the  Cornishmen  in  the  early  days  of 
copper  mining  in  Michigan,  when  it  was  claimed  that 
only  assured  incomes  would  keep  doctors  in  the  newly 
opened  mining  regions.  According  to  the  present  sys- 
tem an  amount  ranging  from  75  cents  to  $1.50  per 
month,  deducted  from  each  employee's  wages,  guar- 
antees the  doctor  an  annual  income  in  return  for  car- 
ing for  all  the  medical  work  of  the  community.  Given 
a  doctor  of  vision  and  energy,  the  system  affords  pos- 
sibilities for  broad  development  of  constructive  health 
work.     But  too  often  it  lends  itself  to  exploitation 

from  both  sides;  the  workers  make  excessive  demands 

369 


IMMIGRANT  HEALTH  AND  COMMUNITY 

for  free  medicine  and  medical  service,  and  the  doctor 
is  often  lax  and  careless. 

The  workers  have  no  choice  in  the  deduction  from 
their  wages  for  medical  work.  They  have  no  control 
over  the  system,  no  voice  in  the  administration  of  the 
funds  or  the  choice  of  the  doctor.  Few  of  the  contract 
doctors  regard  themselves  as  employees  of  the  workers. 
They  are  engaged  and  discharged  by  the  company, 
though  paid  for  by  the  workers.  Representatives  of 
the  mining  companies  generally  seem  to  regard  the 
system  as  "welfare  work."  This  is  also  the  point  of 
view  of  most  of  the  "contract  surgeons."  Many  of 
the  miners  are  indifferent  to  the  question.  Others 
see  in  it  a  just  cause  of  discontent  and  criticism. 
There  is  evidence  that  the  essential  justice  and  effi- 
ciency of  the  system  is  being  questioned.  Everywhere 
symptoms  of  unrest  are  showing  themselves,  and  the 
value  of  the  system  is  being  challenged  on  all  sides. 

In  contrast  to  the  system  in  these  mining  districts 
is  that  prevailing  in  Ohio  and  Illinois.  Here,  accord- 
ing to  the  Insurance  Commissions  of  these  two  states, 
the  contract  system  is  found  much  less  frequently, 
and  although  the  general  community  health  work  is 
of  lower  grade,  a  serious  source  of  unrest  among  the 
workers  is  absent. 

In  a  Pennsylvania  town  in  the  Monongahela  Valley, 
a  plan  has  been  worked  out  whereby  industrial  and 
community  medical  service  is  provided  and  adminis- 
tered jointly  by  the  miners  through  their  unions,  and 
the  company.  Here  membership  in  the  health  pro- 
gram was  voluntary  and  responsibility  and  control 
were  shared  by  all  concerned.  Surely  this  partnership 
contains  the  germs  of  a  system  that  will  work  for 

370 


INDUSTRIAL  HEALTH  WORK 

better  health,  as  well  as  better  feeling  and  understand- 
ing between  the  industry  and  its  workers. 

A  joint  plan  for  health  which  has  had  more  ex- 
tensive application  is  that  of  the  Colorado  Fuel  and 
Iron  Company  of  Pueblo.  The  workers  as  well  as  the 
management  are  represented  on  committees  on  safety 
and  accidents,  and  on  sanitation,  health,  and  housing.^ 
Jurisdiction  over  all  matters  of  health  and  sanitation 
is  in  the  hands  of  these  committees,  and  these  problems 
have  been  dealt  with  entirely  by  this  form  of  organi- 
zation. 

The  testimony  of  persons  immediately  concerned 
points  to  the  success  of  the  plan.  Interest  is  stimu- 
lated on  the  part  of  the  workers,  and  opportunities  for 
self-expression  and  responsibility  are  developed.  Con- 
sidering the  large  numbers  of  foreign  born  engaged  in 
the  mining  industry,  the  importance  to  health  work 
of  a  plan  w^hich  engages  their  co-operation  and  interest 
cannot  be  overestimated.  In  this  way,  as  in  no  other 
so  successfully,  can  American  health  methods  and 
standards  be  adapted  to  the  varying  demands  made 
upon  them. 

SUMMARY 

Industrial  medicine  is  not  only  a  matter  of  health 
technique;  it  is  an  industrial  issue.  In  the  economic 
difficulties  that  grew  up  in  Colorado  in  1913  and  1914 
medical  service  was  distinctly  an  issue.  To-day,  in 
many  factories  and  mines,  an  ill-understood  and  un- 
explained system  of  medical  examination  or  medical 
care  is  a  factor  in  industrial  unrest. 


^  Industrial  Representation  Plan,  Colorado  Fuel  and  Iron  Com- 
pany. 

371 


IMMIGRANT  HEALTH  AND  COMMUNITY 

The  foreign  born  constitute  a  large  proportion  of 
the  employees  in  many  industries;  in  fact,  they  form 
a  majority  of  the  entire  population  in  many  industrial 
communities,  both  large  and  small.  Yet  correspond- 
ence and  conference  with  industrial  physicians,  em- 
ployment managers,  and  others  make  it  clear  that 
relatively  little  attention  has  been  given  to  the  special 
medical  and  health  problems  presented  by  this  im- 
portant labor  element. 

The  value  of  medical  service  to  industry  in  securing 
the  maximum  efficiency  of  labor  is  too  well  established 
to  need  discussion  here.  In  the  many  communities 
where  an  industry  is  the  only  large  and  effective  force, 
its  responsibility  in  this  respect  looms  large.  More- 
over, the  industry  has  a  much  greater  hold  on  its 
employees  than  the  visiting  nurse  or  dispensary  social 
worker  can  usually  acquire,  and  a  consequently  greater 
opportunity  to  get  results  in  curative  and  preventive 
medicine.  Whatever  the  industry's  responsibilities 
and  opportunities  in  regard  to  labor  in  general,  these 
are  intensified  in  the  case  of  the  immigrant  by  his 
comparative  ignorance  and  helplessness  in  his  new 
environment. 

Some  of  the  major  questions  with  which  industrial 
physicians  and  nurses  are  dealing,  are:  the  prevention 
of  accidents;  the  prevention  and,  where  necessary, 
the  treatment  of  occupational  and  other  diseases;  the 
maintenance  and  promotion  of  sanitation  within  the 
plant;  and  of  personal  hygiene  among  the  workers. 

Industrial  medicine  must  justify  itself  on  a  business 
basis,  and  to  achieve  profitable  results  it  must  fulfill 
certain  requirements.  It  must  specialize  in  human  as 
well  as  in  medical  relations.    Knowledge  and  consid- 

372 


INDUSTRIAL  HEALTH  WORK 

eration  of  immigrant  backgrounds  are  essential  to 
overcoming  the  barriers  of  language  and  point  of  view. 
The  method  of  approach  to  the  employee  should  be 
democratic,  not  paternalistic,  and  every  effort  should 
be  made  to  enlist  him  m  the  support  and  the  adminis- 
tration of  industrial  medicine. 

One  kind  of  industrial  medicine  that  will  never  pay 
is  the  cheap  kind.  Good  physicians  require  adequate 
salaries.  It  is  the  cheap  men  who  conceive  of  and 
treat  people  cheaply.  The  keen,  well-trained  doctor 
appreciates  the  vital  importance  of  the  human  factor 
in  medical  and  business  efficiency,  and  will  perceive 
and  strive  to  deal  with  the  special  problems  of  the 
immigrant  employee. 

The  industrial  physician  should  be  directly  respon- 
sible to  one  of  the  high  officials  of  his  plant,  as  the 
head  of  any  major  department  would  be.  Only  in 
that  way  will  the  full  value  and  importance  of  the 
medical  work  be  realized. 

The  larger  problem  of  industrial  medicine  hinges 
upon  the  question  of  its  place  in  community  health 
work.  How  far  should  it  go  beyond  the  walls  of  the 
plant  itself?  Not  a  few  industries  have  undertaken 
housing  for  employees,  partly  for  sanitary,  partly  for 
other  reasons.  Medical  care  has  been  extended  to 
employees  in  their  homes  and  sometimes  to  their  fam- 
ilies as  well,  in  many  minmg  communities,  and  in 
some  factories  and  labor  camps. 

The  contract  system,  as  developed  in  the  iron  and 
copper  ranges  of  Minnesota  and  Michigan,  is  in  the 
main  a  creature  of  the  employer  rather  than  of  the 
community,  and  has  the  essential  limitations  of  the 
manner  of  its  creation.    It  is  apparent  that  in  a  newly 

25  2^3 


IMMIGRANT  HEALTH  AND  COMMUNITY 

opened  country  the  contract  system  will  assure  the 
employees  and  their  families  medical  services  which 
would  be  beyond  their  reach  if  the  industry  did  not 
come  forward.  But  almost  everywhere  it  is  in  use  it 
shows  the  evils  of  any  scheme  of  medicine  which  is  on 
a  commercial  basis,  but  which  has  not  developed  with 
the  understanding  and  co-operation  of  those  who  are 
to  receive  its  care. 

The  entrance  of  industry  into  community  medical 
care  has  been  frequently  observed  to  coincide  with  a 
low  level  of  public-health  work  in  the  same  area.  This 
is  particularly  true  in  regions  where  the  community 
consists  largely  of  foreign-born  employees  too  recently 
immigrated  to  take  much  part  in  normal  community 
activities. 

A  marked  contrast  could  be  drawn  between  the 
conditions  described  on  the  iron  and  copper  ranges  in 
northern  Minnesota  and  Michigan,  where  practically 
all  the  medical  and  health  work  is  done  by  the  indus- 
try for  the  community,  and  the  situation  in  Akron, 
Ohio.  Several  large  industries  in  Akron  have  their 
own  well-developed  departments  of  industrial  medi- 
cine; they  have  also  bent  their  efforts  to  a  notable 
degree  to  advance  and  assist  the  health  work  of  the 
community  under  the  city  government.  Where  in- 
dustry has  a  farsighted  view  instead  of  a  short-range 
commercial  one,  it  will  encourage  community  health 
work  and  not  substitute  industrial  medicine  for  it. 

On  the  whole,  except  temporarily  under  pioneer 
conditions,  the  development  of  industrial  medical 
service  outside  the  industrial  establishment  itself  must 
be  regarded  as  an  influence  against  Americanization 
in  the  larger  sense,  and  against  the  more  permanent 

374 


INDUSTRIAL  HEALTH   WORK 

interests  of  the  communities'  medical  and  health  work. 
If  the  administration  of  industrial  organizations,  and 
therefore  industrial  medicine,  were  wholly  co-opera- 
tive and  democratic,  this  might  not  be  true.  But 
under  present  conditions  it  is  to  be  hoped  that  medical 
and  health  resources  will  be  developed  and  strength- 
ened as  much  as  possible  from  community  rather  than 
from  direct  industrial  resources. 

Industry  should  do  its  share  as  a  part  of  the 
community,  but  not  more  than  its  share.  The  initia- 
tive and  self-dependence  of  immigrants  and  their  fam- 
ilies, and  their  understanding  of  the  purposes  and 
methods  of  medical  and  health  work,  can  be  pro- 
moted only  when  they  have  responsibility  and  par- 
ticipation as  citizens. 

Mr.  Whiting  Williams  ^  of  Cleveland,  in  an  article 
printed  for  circulation  by  the  United  States  Depart- 
ment of  Labor,  says: 

The  price  of  maximum  production  is  maximum  per- 
sonality for  every  human  producer.  Of  this,  the  price  is 
maximum  outlet  for  that  human  producer's  best  and 
biggest  feelings.  That  in  turn  can  be  bought  only  with 
right  relationships  and  associations  with  aU  the  persons 
of  his  world.     Of  that  the  price  and  the  prize  is  democracy. 

^  Whiting  Williams,  Human  Relations  in  Industry,  leaflet  printed 
by  the  United  States  Department  of  Labor,  1918. 


XVII 

PUBLIC    HEALTH    WORK 

The  health  department  is  the  fundamental  agent  of 
the  community  to  serve,  protect,  and  advance  the 
physical  well-being  of  its  members.  Any  survey  of 
American  policies  and  methods  in  medical  and  health 
work  leads  to  the  health  department.  Any  program 
of  medical  and  health  work  must  place  in  the  fore- 
ground the  policies  and  methods  of  the  health  depart- 
ment, as  they  are  or  as  they  should  be.  In  order  to 
secure  material  for  this  study  public-health  officials 
in  all  cities  of  25,000  population  and  over  were  asked 
to  state  what  special  problems  they  have  met  in  deal- 
ing with  the  foreign  born,  and  what  methods  they 
have  used  in  solving  them. 

From  the  answers  it  is  apparent  that  the  special 
problems  of  health  standards  and  care  among  the 
foreign  born  have  made  very  little  impression  on  the 
mind  of  the  average  health  officer.  To  be  sure,  one 
finds  striking  exceptions  to  this  rule,  which  only  bring 
into  greater  relief  the  indifference  of  the  large  majority. 

The  reason  for  the  apparent  neglect  of  such  an  im- 
portant element  in  health  work  is  clear.  Public-health 
administration,  in  the  majority  of  cases,  is  just  be- 
ginning to  come  into  its  own  as  to  equipment,  trained 
personnel,  and  a  modern  conception  of  the  powers 
and  duties  of  the  department.    With  the  exit  of  the 

"yellow  flag"  and  "shotgun"  quarantine  methods 

376 


PUBLIC  HEALTH  WORK 

have  come  careful  analysis  of  the  causes  of  disease, 
and  the  application  of  rational  methods  to  its  preven- 
tion and  control. 

Valuable  answers  were  received  from  116  health 
officers.  As  the  outstanding  health  problems  of  the 
foreign  born,  64  per  cent  mentioned  housing  and  home 
sanitation,  44  per  cent  child  and  infant  welfare,  and 
32  per  cent  care  of  contagious  diseases.  In  discussing 
these  problems  all  points  of  view  were  expressed. 

Too  often  there  appeared  the  attitude  that  the 
foreign  born  *'lack  willingness  to  learn  the  precau- 
tions of  health."  Based  on  this  premise  is  the  in- 
evitable conclusion  that  the  only  way  to  deal  with 
health  situations  involving  the  foreign  born  is  the 
big-stick  method.  The  head  of  a  middle-sized  city  in 
New  York  (x\lbany)  says  with  emphasis  that  the  only 
way  to  control  communicable  disease  among  the  foreign 
born  is  by  police  quarantine.  In  this  he  is  seconded 
by  one  of  the  larger  cities  of  the  Far  West  (Denver) . 

It  is  refreshing  to  find  in  Texas  (Beaumont)  an 
official  who  is  sure  that  we  can  educate  the  immigrants 
to  believe  that  the  health  department  is  to  benefit 
and  not  to  prosecute  them.  This  feeling  is  more  than 
confirmed  by  a  Massachusetts  (Springfield)  health 
officer  of  long  experience,  who  says  *'that  they  can  be 
educated — that  they  cannot  be  controlled  by  prosecu- 
tion. Further,  that  if  we  make  the  right  approach 
the  average  foreign-born  person  will  respond  to  efforts 
and  carry  out  our  recommendations . '  *  A  public-health 
nurse  m  Massachusetts  (North  Adams)  testifies  that 
"as  a  rule  the  foreign  born  respond  to  advice  and 
carry  out  instructions  as  faithfully  as  our  own  people 

iu  the  same  circumstances." 

377 


IMMIGRANT  HEALTH  AND   COMMUNITY 

Inquiries  were  made  as  to  methods  of  reaching  the 
foreign  born.  Very  few,  if  any,  of  the  health  officials 
in  the  country  have  any  special  program  laid  out  for 
the  foreign  born.  It  is  true  that  we  find  a  great  many 
clinics,  public-health  nurses,  health  centers,  and  wel- 
fare centers  established  in  the  foreign  quarters,  but 
investigation  shows  that  these  centers  are  established 
to  provide  general  medical  care  for  the  poor,  and  the 
solution  of  the  problems  of  the  foreign  born  is  of  sec- 
ondary importance. 

These  methods  have  been  discussed  as  such  in 
earlier  chapters.  The  point  of  view  of  various  health 
officers  toward  them  is  significant.  The  following 
testimonies  are  typical.  A  Middle- Western  health 
officer  says: 

Force  them  to  use  the  "American  language."  We  have 
Welfare  Stations  with  Americans  in  charge.  I  will  not 
employ  any  who  talks  to  them  in  a  foreign  language.  It 
is  up  to  them  to  learn  English — not  us  to  learn  their  lan- 
guages.    I  have  no  patience  with  less  strenuous  methods. 

With  this  can  be  contrasted  the  statement  of  the  health 
officer  of  one  of  our  modern  Eastern  departments 
(Newark,  New  Jersey),  who  says: 

We  believe  until  such  time  as  English  is  universally  spoken 
we  should  endeavor  to  reach  the  foreigner  by  all  possible 
means. 

He  backs  this  opinion  by  providing,  in  every  part  of 
his  department,  a  line  of  communication  to  the  foreign 
born  in  their  own  languages. 

Intensive  study  of  certain  outstanding  experiments 
in  community  health  work  brings  out  more  suggestive 
evidence  than  did  correspondence.  With  the  excep- 
tion of  a  few  middle-sized  communities,  such  as  Erie, 

378 


PUBLIC  HEALTH  WORK 

Pennsylvania,  and  Bridgeport,  Connecticut,  the  items 
of  interest  are  chiefly  from  cities  of  the  first  class.  In 
these  the  health  departments  have  been  of  sufficient 
magnitude  to  develop  full-time  expert  personnel  along 
various  special  lines  of  medical  and  health  work,  as 
well  as  in  their  general  administrative  staffs.  The 
large  cities  have  thus  naturally  served  as  experiment 
stations  and  leaders  in  professional  development. 
Voluntary  organizations  supported  by  private  funds 
have  also  conducted  a  number  of  pieces  of  work  in 
large  cities  which  are  of  almost  equal  interest  with  the 
imdertakings  of  health  departments. 

The  most  important  single  step  made  by  health 
departments  toward  effective  methods  of  work  with 
the  immigrant  has  been  the  employment  of  visiting 
nurses  to  do  infant-welfare  or  tuberculosis  work, 
school  nursing,  prenatal  work,  or  general  public-health 
nursing,  including  these  and  sometimes  other  lines. 
Formerly,  the  only  point  of  contact  between  the 
health  department  and  the  average  family  was  a 
distant  central  office,  with  a  formal,  if  not  political, 
atmosphere,  to  which  people  rarely  resorted  except 
at  the  summons  of  the  poHce  or  to  lodge  their  com- 
plaints. The  visiting  nurse  has  taken  health  work 
to  the  people.  She  has  put  it  into  terms  of  daily 
personal  life. 

The  same  methods  which  make  nursing  service 

under  private  associations  effective  in  dealing  with  the 

immigrant  will  be  successful  in  state  and  municipal 

health  departments.    Since  this  technique  has  already 

been  considered,  our  present  interest  in   surveying 

notable   developments   by   health   departments   and 

voluntary  associations  in  the  same  field  is  in  their 

379 


IMMIGRANT  HEALTH  AND  COMMUNITY 

organization  and  their  relations  to  other  community 
agencies. 

The  use  of  visiting  nurses  naturally  promotes  locali- 
zation. Districting  is  an  obvious  means  to  efficiency 
in  administering  visiting-nursing  service  in  any  large 
city.  Experience  has  shown  that  the  tuberculosis, 
baby,  and  other  health  clinics  that  have  developed 
simultaneously  with  visiting  nursing,  are  also  most 
effective  when  brought  close  to  the  people.  For  ex- 
ample, large  centrally  located  clinics  for  diagnosis  and 
treatment  of  sick  babies  are  essential,  but  to  do  infant- 
welfare  work  along  preventive  lines  on  any  extensive 
scale  it  has  everywhere  been  found  necessary  to  have 
a  number  of  "  infant- welfare  stations,"  or  local  baby 
clinics,  each  serving  a  small,  definite  area.  The  visit- 
ing nurses  have  naturally  been  attached  to  the  clinics. 

The  developments  studied  here  relate  chiefly  to 
methods  of  intensive  localized  medical  or  health  work, 
and  to  the  co-ordination  of  intensively  organized  local 
health  districts  one  with  another  and  with  the  medical 
and  health  work  of  the  city  as  a  whole.  It  has  recently 
become  the  fashion  to  call  this  the  health-center  move- 
ment, but  this  term  lacks  exact  definition  and  is  being 
used  to  cover  a  variety  of  undertakings.  It  will  not, 
therefore,  be  employed  here  except  in  an  illustrative 
way.  The  history  of  its  development  can  be  found 
elsewhere.^ 

EXPERIMENTS   IN   NEW   YORK 

A  certain  number  of  organizations  have  consciously 
sought  to  develop  neighborhood  co-operation  in  the 

^  Michael  M.  Davis,  Jr.,  Public  Health  Nurse  Quarterly,  January, 
1916. 

380 


PUBLIC  HEALTH  WORK 

district  receiving  the  health  service.  One  of  the 
earhest,  if  not  the  earhest  attempt  in  this  direction, 
was  made  by  the  New  York  Milk  Committee  in  1913, 
in  establishing  a  health  center  on  the  lower  West  Side 
of  Manhattan. 

The  section  selected  was  largely  populated  by  Syri- 
ans, with  a  proportion  of  Irish-Americans  and  native 
born.  It  was  a  district  with  comparatively  poor 
housing  conditions  and  limited  medical  resources.  A 
thorough  canvass  of  the  residents  was  made  during  the 
first  two  years  of  the  health  center.  The  Bowling 
Green  Neighborhood  Association,  composed  of  resi- 
dents and  of  friends  and  specialists  from  outside,  was 
formed  to  administer  the  activities  of  the  center. 
These  were  chiefly  mfant  welfare  and  prenatal  work, 
but  the  program  ran  beyond  the  health  field,  and 
illustrated  the  wisdom  of  expanding  the  interests  of  a 
neighborhood  group  beyond  a  single  specialized  ac- 
tivity. As  an  experiment  in  practical  Americaniza- 
tion, the  "Bowling  Green"  imdertaking  is  weU  worth 
careful  study. 

It  has  been  characteristic  of  almost  all  these  endeav- 
ors that  they  have  been  conducted  in  districts  pre- 
dominantly mhabited  by  comparatively  recent  immi- 
grants and  their  children.  Thus  the  most  ambitious 
attempt  to  apply  the  principle  of  localization  in  the 
administration  of  health  work  was  made  by  the 
Health  Department  of  New  York  City  in  1915  in  a 
district  on  the  lower  East  Side  of  Manhattan,  almost 
entirely  populated  by  Jewish  people.  The  scheme  can 
be  most  readily  shown  by  the  tabulation  on  the 
following  page. 

The  health  officer  of  the  district  was  a  Jewish  physi- 

381 


IMMIGRANT  HEALTH  AND  COMMUNITY 

cian  who  understood  the  people,  their  language,  back- 
grounds, and  characteristics.  The  three  nurses  and  the 
nurses*  assistant,  as  will  be  seen  from  the  tabulation, 
were  each  performing  several  functions,  instead  of  one. 
Thus,  under  ordinary  conditions,  no  home  would  have 


HEALTH   DISTRICT   No.   1 

New  York  City  Health  Department 


Functions  Performed 

District  Staff 

Supervising  Staff 

1. 

Prenatal  work 

Health  officer  of  dis- 

Health Commis- 

2. 

Infants'  milk  sta- 

trict (part  time)  in 

sioner 

tion 

full  local  adminis- 

or 

3. 

Examination     of 

trative  charge 

Deputy- 

children,     pre- 

Medical inspector 

Bureau  chiefs  of 

school  age 

(part  time) 

1.  Child  hygiene 

4. 

Medical     inspec- 

Functions 2,  3,  4 

2.  Preventable 

tion  of  school 

Three  nurses 

diseases 

children 

Functions  1-7 

3.  Food  inspection 

5. 

Supervision    of 

One  nurse's  assistant 

4.  Sanitation 

midwives    and 

Function  2 

5.  Public  health  ed- 

foundlings 

Food    inspector 

ucation 

6. 

Tuberculosis    su- 

(part time) 

pervision 

Sanitary  inspector 

7. 

Other    infectious 
diseases 

(part  time) 

8. 

Food    inspection 

9. 

General      sanita- 
tion 

10. 

Public     health 
education 

more  than  one  nurse  as  a  visitor.  The  contacts  be- 
tween the  people  of  the  district  and  the  health  de- 
partment were  simplified  and  strengthened  in  three 
ways: 

1,  By  visibly  localizing  the  health  department's 

work  in  an  office  in  the  center  of  the  twenty-one 

382 


PUBLIC  HEALTH  WORK 

blocks  housing  the  25,000  inhabitants  of  that  highly 
congested  area. 

2.  By  making  a  single  official,  who  was  chosen  for 
his  familiarity  with  the  human  as  w^ell  as  the  public- 
health  factors  of  the  work,  and  who  was  in  daily  local 
attendance,  the  center  for  most  official  contacts  be- 
tween department  and  populace. 

3.  By  emphasizing,  through  the  generalized  nurs- 
ing service — one  nurse  to  a  family — the  personal 
elements  as  distinguished  from  the  professional 
elements. 

It  is  said  that  among  both  the  physicians  of  the 
district  and  the  general  population,  a  noteworthy 
increase  in  efficiency  and  friendliness  developed  dur- 
ing the  rather  short  period  that  this  interesting  ex- 
periment was  in  effective  progress. 

This  scheme  involves  the  same  principle  of 
"line"  and  "staff"  organization  with  which  army 
procedure  has  made  us  familiar,  and  which  is  gen- 
erally applied  in  public-school  systems  and  other 
large  enterprises.  The  "staff"  is  a  group  of  experts, 
each  concerned  with  a  special  function  or  group  of 
functions.  The  "line"  officers  and  employees  are 
concerned  with  administering  the  work  in  its  various 
functions. 

Thus,  in  this  East  Side  health  center,  the  bureau 
chiefs  were  "staff"  supervisors,  each  watching  criti- 
cally the  performance  of  the  special  functions  which 
came  under  his  or  her  bureau.  The  local  health  officer 
and  the  nurses  and  others  under  him  were  "line" 
officers  or  employees.  Further  experiments  of  this 
type  will  be  required  to  establish  the  desirability  of 
such  a  scheme  of  localized  health  administration.    In- 

383 


•9 

IMMIGRANT  HEALTH  AND  COMMUNITY 

herent  in  it  are  principles  of  successful  medical  and 
health  work  with  the  foreign  born. 

HEALTH  CENTERS  IN  CLEVELAND 

New  York  City  is  not  alone  in  the  development  of  dis- 
trict schemes.  Cleveland  has  a  system  of  health 
centers  (at  present  eight  in  number,  but  probably  soon 
to  be  increased)  in  charge  of  the  health  department. 
Their  work  includes  tuberculosis  and  preventive  serv- 
ice for  mothers  and  babies,  and  each  serves  a  definite 
district. 

The  health-department  nurses  do  all  the  work  ex-; 
cept  bedside  nursing.  One  of  these  health  centers  is 
the  so-called  University  Teaching  District.  The  su- 
pervising nurse  is  an  appointee  of  the  Western  Reserve 
University  Medical  School,  who  retains  also  a  relation 
to  the  health  department.  The  five  nurses  under  her 
have  each  a  special  section  of  the  district,  and  do 
general  and  bedside  nursing,  as  well  as  special  work. 
The  training  of  public-health  nurses  is  also  carried 
pn  here. 

In  this  district  the  population  is  largely  foreign  born. 
One  nurse  has  a  considerable  proportion  of  Italians; 
another,  almost  all  Slavs;  still  another,  many  Jews; 
still  another,  a  "  great  mixture."  The  localization  and 
districting  of  the  work  appears  to  have  brought  about 
much  greater  interest  in  the  human  factors,  including 
the  factor  of  race. 

The  plan,  which  divides  the  district  up  into  small 
sections,  each  in  charge  of  one  nurse,  appears  to  have 
interested  each  nurse  in  the  special  problems  of  her 

people;  to  have  made  her  familiar  with  the  particular 

384 


PUBLIC  HEAXTH  WORK 

races  or  other  groups  characteristic  of  her  area,  and 
to  have  increased  the  intensiveness  and  the  extent  of 
both  social  and  professional  contacts.  The  tendency 
of  such  a  plan  is  to  produce  more  work  than  a  given 
staff  can  carry.  This  is  the  best  evidence  of  its  suc- 
cess, since  the  ultimate  purpose  of  such  health  work 
is  to  cause  a  growing  demand  for  the  service.  The 
goal  is  to  meet  100  per  cent  of  the  needs. 

CO-ORDINATION   IN   BUFFALO 

In  Buffalo  the  health  department  and  the  co-ordinate 
Department  of  Hospitals  and  Dispensaries  co-operate 
in  administering  health  centers.  Five  such  centers 
are  maintained  in  different  parts  of  the  city,  in  each 
of  which  infant  welfare,  antituberculosis,  and  prenatal 
work  is  conducted.  Localization  is  carried  still 
farther  in  the  infant- welfare  work  by  eight  "well-baby 
clinics"  outside  the  centers,  but  part  of  the  same  sys- 
tem. Five  district  physicians  are  employed  on  salary 
by  the  Department  of  Hospitals.  Each  physician 
treats  the  sick  in  their  homes  and  also  runs  a  general 
clinic  in  the  district  health  center,  of  which  he  is  in 
general  charge.  Four  of  the  five  health  centers  have 
dental  clinics.  Thus  curative  and  preventive  medicine 
are  combined,  although  not  wholly,  under  a  single 
direction. 

The  first  of  these  Buffalo  health  centers  was  located 
in  rented  quarters  in  a  distinctly  Polish  district,  but 
the  development  of  the  service  has  justified  the  pro- 
vision of  a  new  building  especially  for  the  purpose. 
The  localization  of  both  preventive  and  curative  work 

appears  to  have  demonstrated  its  value  to  the  com- 

385 


IMMIGRANT  HEALTH  AND   COMMUNITY 

munity  in  Buffalo.    Here  again  the  people  to  whom 
the  services  are  rendered  are  largely  foreign  born. 


A   DISPENSARY   IN   BOSTON 

The  Maverick  Dispensary,  Boston,  represents  a  num- 
ber of  agencies  brought  together  in  a  single  building 
in  a  district  peopled  largely  by  Italians.  A  general 
medical  clinic,  morning  and  evening,  eye  and  dental 
clinics  for  both  children  and  adults,  and  an  obstetrical 
clinic  are  included  in  the  curative  work  of  the  dis- 
pensary proper.  The  physician  who  is  in  charge  of 
the  general  clinic  visits  and  treats  patients  in  their 
homes.  The  District  Nursing  Association  of  Boston 
has  its  local  headquarters  in  the  building.  Its  nurses 
do  bedside  nursing  and  prenatal  work  in  the  district. 
The  local  "well-baby  station"  was  formerly  in  the 
building,  but  has  been  driven  out  by  lack  of  space. 
It  is,  however,  in  the  immediate  neighborhood,  and 
works  in  close  co-operation  with  the  dispensary.  The 
local  clinics  act  as  referring  stations  from  which 
patients  are  sent  to  the  large  dispensaries  and  hos- 
pitals equipped  for  more  elaborate  work  or  for  major 
operations. 

Boston  is  as  fully  provided  as  any  city  in  the  country 
with  general  dispensary  service.  Yet  the  development 
of  this  local  dispensary  in  a  section  largely  foreign 
born  seems  to  be  fully  justified  during  recent  years  by 
the  rapid  and  steady  increase  in  the  number  of  cases 
cared  for.  The  number  of  visits  to  the  treatment 
clinics  increased  from  7,044  in  1915,  to  10,859  in  1918, 
a  growth  of  over  50  per  cent.    Undoubtedly  friendly 

contact  with  this  local  center  has  served  to  familiarize 

386 


PUBLIC  HEALTH  WORK 

many  foreign-born  families  with  American  medical 
resources. 

THE   SOCIAL   UNIT  PLAN 

Much  the  most  comprehensive  attempt  to  enlist  and 
organize  the  co-operation  of  a  district  has  been  that 
of  the  National  Social  Unit  Organization  in  Cincm- 
nati.  The  so-called  Mohawk-Brighton  District,  in 
which  the  experiment  has  been  conducted,  has  a 
population  of  about  15,000,  between  5  and  10  per 
cent  of  which  are  recent  immigrants.  These  are 
mostly  Rumanians  and  Hungarians,  who  live  in  one 
corner  of  the  district  and  are  in  large  proportion  men 
without  families.  The  bulk  of  the  district  is  a  com- 
paratively long  settled  and  stable  family  population 
of  German-American  stock.  The  findings  of  the  So- 
cial Unit  Plan  are  therefore  limited  in  their  applica- 
tion to  the  problems  of  the  foreign  born. 

Activities  up  to  the  time  of  this  writing  have  been 
chiefly  along  health  lines,  consisting  largely  of  mf ants', 
children's,  and  prenatal  work.  Medical  examinations 
and  advice  were  given  following  the  influenza  epi- 
demic. A  statement  dated  January,  1919,  gives  an 
account  of  the  "baby  service." 

The  first  service  to  be  established  for  the  neighborhood 
was  a  baby  service  which  was  decided  upon  by  the  Mohawk- 
Brighton  Citizens  and  Occupational  Councils  and  opened 
on  December  17,  1917.  It  was  found  at  once  that  because 
the  block  workers  were  elected  representatives  of  the 
blocks,  because  they  were  neighbors  of  the  babies'  mothers, 
the  work  of  discovering  the  babies  and  of  iuteresting  the 
mothers  in  bringiug  them  to  the  station  was  greatly  sim- 
plified.   The  doctors  and  nurses  also  were  neighborhood 

387 


IMMIGRANT  HEALTH  AND  COMMUNITY 

representatives,  and  it  became  a  matter  of  pride  to  have 
one's  baby  examined.  It  was  not  considered  that  the 
health  station  was  in  any  sense  a  charity  institution. 

As  a  result  of  these  unique  features  and  of  the  general 
educational  program  on  infant  care,  conducted  by  the 
neighborhood  itself  through  its  own  physicians,  nurses, 
and  elected  block  representatives,  in  four  months  every  one 
of  the  297  babies  under  one  year  of  age  was  under  nursing 
supervision,  and  70  per  cent  had  been  given  examinations 
by  the  medical  staff.  As  babies  are  born,  they  at  once 
come  under  the  nursing  care.  Also,  the  baby  service  has 
been  extended  to  include  babies  between  one  and  two  years 
of  age,  and  at  present  every  baby  under  two  is  under 
nursing  supervision.  Of  these,  410,  or  90  per  cent,  have 
visited  the  health  station  and  have  had  careful  physical 
examinations,  and  many  are  returning  at  regular  intervals 
for  preventive  oversight  by  the  physicians,  being  referred 
to  their  family  doctors  for  curative  care. 

This  remarkable  achievement  of  reaching  nearly 
100  per  cent  of  the  babies  was  undoubtedly  due  to  the 
careful  organization  of  the  district,  block  by  block. 
Each  block  has  its  "worker,"  who  is  paid  a  certain 
amount  for  the  time  she  gives.  The  block  workers 
together  make  up  a  "council"  with  a  salaried  execu- 
tive, who  has  an  office  at  the  central  station  of  the 
Social  Unit  in  the  district.  She  is  the  organizer  and 
leader  for  her  neighborhood. 

The  six  nurses,  one  of  whom  gives  her  time  to  super- 
vision, and  five  to  field  work,  get  all  sorts  of  informa- 
tion from  the  block  workers  regarding  the  conditions 
and  needs  of  families,  and  are  thus  placed  in  friendly 
and  intimate  contact  with  the  people. 

Up  to  the  time  of  writing,  however,  very  little  has 
been  done  to  connect  the  men  of  the  district  with  the 
health  program.     This  partly  explains  why  it  has 

388 


PUBLIC  HEALTH  WORK 

failed  to  reach  the  Rumanians,  Hungarians,  and  other 
recent  immigrants. 

No  special  attempt  seems  to  have  been  made  to 
reach  these  immigrants  or  to  see  that  some  one  of 
their  group  whom  they  felt  to  be  representative  of 
themselves  and  their  interests  was  brought  into  the 
neighborhood  organization.  The  block  workers  seem 
to  have  the  not  infrequent  "American"  attitude  of 
indifference  toward  them  or  at  least  a  strong  sense  of 
separateness  from  them.  It  is  apparent  that  even  a 
small  proportion  of  foreign  born  may  greatly  compli- 
cate the  neighborhood  organization  of  a  community. 
The  plain  people,  who  constitute  neighborhood  or- 
ganizations, are  not  likely  to  be  any  more  free 
from  race  or  national  prejudice,  or  to  be  imbued 
with  any  higher  ideas  of  practical  democracy  than 
the  people  who  work  out  schemes  for  neighborhood 
organization. 

Therefore  the  Cincinnati  Social  Unit  has  not  made 
a  contribution  toward  the  closer  interrelation  of  native 
and  foreign  born.  It  was  not  established  with  this 
particular  end  in  view,  nor  was  the  district  selected 
one  which  would  make  it  possible  to  accomplish  much 
in  this  direction.  The  district  does,  however,  contain 
a  sufficient  proportion  of  recent  immigrants  to  make 
it  wise  that  a  deliberate  effort  be  made  to  work  them 
effectively  and  democratically  into  the  neighborhood 
organization  before  the  term  of  the  experiment  is 
completed. 

Much  of  value  can  be  got  from  the  Cincinnati  Social 
Unit  for  our  general  program  of  medical  and  health 
care  for  the  foreign  born.  Its  technique  of  neighbor- 
hood organization  is  capable  of  general  application, 

26  389 


IMMIGRANT  HEALTH  AND  COMMUNITY 

with  such  modifications  as  would  render  the  scheme 
simpler  and  less  expensive. 

The  unit  has  thrown  into  the  foreground  one  vital 
principle.  It  has  taken  into  its  confidence,  on  a 
democratic  basis,  the  people  who  are  to  be  served,  so 
that  they  understand  and  appreciate  the  services  and 
participate  in  the  guidance  of  its  policies.  Merely  to 
throw  this  principle  into  relief,  to  illustrate  it  so  that 
it  will  be  talked  about  and  thoughtfully  considered 
all  over  the  country,  has  been  a  contribution  of  high 
value. 


Part  V 
A  PROGRAM  FOR  HEALTH 


XVIII 

COMMUNITY   ORGANIZATION 

If  one  needed  to  be  convinced  of  the  seriousness  of 
the  immigrant  health  problem  in  this  country,  a  glance 
at  available  sickness  and  death  rates  would  be  suffi- 
cient.   The  general  terms  of  the  situation  are  as  fol- 
lows.   The  physical  and  social  environment  in  which 
the  average  immigrant  finds  himseK  in  America  con- 
tains elements  that  seriously  menace  his  health.    Un- 
sanitary housing  almost  automatically  falls  to  his  lot. 
The  balance  of  his  dietary  is  upset  by  inabihty  to 
secure  familiar  foodstuffs.    His  occupation  is  changed 
without  a  corresponding  change  in  his  way  of  livmg. 
His  medical  service  is  in  large  part  supplied  by  the 
midwife  and  the  quack.    His  comparative  ignorance 
and  his  comparative  poverty  often  make  it  impossible 
for  him  not  only  to  secure  the  best  in  our  complicated 
society,  but  even  to  use  the  advantages  that  come 
under  his  hand. 

The  immigrants  themselves  have  made  an  effort  to 
meet  the  burden  of  sickness  by  organizmg  benefit 
societies,  but  their  measures  are  madequate  to  the 

situation. 

American  agencies  and  methods  of  work  with  the 
foreign  born  are  gradually  bemg  developed.  The 
nurse,  the  hospital,  the  dispensary,  the  employer,  and 

393 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  health  officer  have  each  contributed  something, 
either  in  plan  or  practice,  to  the  large  problem  of  the 
health  of  the  immigrant.  Although  relatively  little 
serious  attention  has  been  given  to  special  methods  of 
work  with  the  immigrant,  by  most  health  departments 
and  hospitals,  certain  promising  lines  of  work  have 
been  developed,  chiefly  in  health  centers,  and  a  certain 
amount  of  technique  has  been  worked  out  by  visiting 
nurses  and  social-service  workers. 

But  has  there  been  in  any  instance  a  comprehensive 
plan  for  the  whole  situation.?  Can  any  one,  or  all  of 
these  organizations,  working  independently,  be  said  to 
be  adequate?  Throughout  our  considerations  of  these 
agencie;s  in  their  work  with  the  foreign  born,  an 
attempt  has  been  made  to  keep  in  mind  the  way  the 
individual  immigrant  views  things.  From  his  point 
of  view  has  health  service  been  satisfactory.?  If  it 
has  not  been  adequate  or  satisfactory,  what  has  stood 
in  its  way.? 

There  are  four  limitations  upon  the  extent  and 
quality  of  medical  care  which  this  part  of  our  popu- 
lation receives.  They  are  economic,  psychological, 
professional,  and  social.  A  study  of  these  will  give 
the  basis  for  a  more  comprehensive  plan. 

THE   ECONOMIC   LIMITATION 

The  immigrant  has  not  enough  income  to  pay  for 
what  he  and  his  family  need  in  case  of  sickness.  Recent 
studies  *  of  the  United  States  Bureau  of  Labor  Sta- 
tistics have  shown  that  in  1918-19,  among  a  large 

^  Monthly  Labor  Review,  United  States  Bureau  of  Labor  Statistics, 
November,  1919,  p.  19. 

394 


COMMUNITY  ORGANIZATION 

number  of  families  in  thirty  representative  cities,  the 
yearly  expenditure  per  family  for  health  ranged  from 
$31.27  to  $92.77,  averaging  $58.  This  sum  included 
expenditure  for  doctor,  dentist,  oculist,  hospital,  and 
medicines.  Unfortunately  these  data  do  not  separate 
the  native  from  the  foreign-born  families,  so  that  it 
is  not  possible  to  compare  their  expenditures. 

Previous  to  the  war  the  incomes  of  most  of  our 
wage-earning  population  did  not  exceed  $100  per 
month  per  family,  and  many  had  less  than  $1,000  per 
year.  There  must  be  thousands  of  cases  where  ex- 
penditure for  medical  care  in  ordinary  illness  is  out 
of  the  question,  and  the  cost  of  a  grave  emergency 
involves  the  sacrifice  of  small  savings  or  actual  debt. 
Unfortunately,  it  is  in  this  class  that  a  great  many 
immigrant  families  fall. 

It  is,  however,  true  that  the  economic  limitation  is 
not  wholly  a  question  of  income.  All  immigrants  are 
not  poor  in  the  technical  sense  of  dependency.  It  is 
a  question  of  income  in  relation  to  the  standard  of 
living.  Families  with  two  or  three  generations  of 
American  ancestry  and  with  incomes,  let  us  say,  of 
$1,800  or  $2,500  a  year,  usually  include  in  their  con- 
ception of  life  many  activities  and  requirements  with 
which  the  immigrant  is  unfamiliar. 

In  ordinary  terms  we  say  that  this  American  stand- 
ard of  living  is  higher  than  that  of  the  immigrant. 
Among  other  things,  the  American  family  is  accus- 
tomed to  provide  the  service  of  a  private  doctor  for 
its  members  during  niness.  They  allow  for  this  as 
far  as  they  can  in  making  up  their  annual  budget  or 
in  planning  the  expenditure  of  their  income. 

The  combination  of  a  so-caUed  low  standard  of 

395 


IMMIGRANT  HEALTH  AND  COMMUNITY 

living,  with  considerable  financial  reserve  in  emer- 
gency, is  a  characteristic  frequently  noted  by  workers 
among  the  immigrants.  A  doctor  tells  of  an  obstetri- 
cal case  in  which  the  free  services  of  an  institution 
were  at  first  sought,  but,  owing  to  difficulty  and  delay 
at  the  critical  moment,  $60  was  finally  paid  in  cash  to 
a  private  physician  to  deliver  the  woman. 

It  has  not  always  been  appreciated  that  savings  are 
part  of  the  standard  of  living  in  many  immigrant 
families.  They  pursue  a  standard  of  life  more  or  less 
like  that  to  which  they  have  been  accustomed  in 
Europe,  with  certain  adaptations  to  the  American 
environment.  They  receive  more  money  wages  than 
ever  before,  and  sometimes  put  much  by.  A  native 
family  with  the  same  income  but  a  different  standard 
would  spend  more  and  save  less,  because  they  would 
be  unwilling  to  sacrifice  present  comfort,  health,  or 
seK-development.  The  immigrant  does  not  appreciate 
that  he  is  making  a  sacrifice. 

It  is  only  gradually,  as  he  becomes  accustomed  to 
American  wage  scales,  American  living  conditions, 
American  opportunities,  that  he  begins  to  adjust  his 
spending  and  his  saving  to  what  we  call  the  American 
standard.  Before  this  happens  there  is  a  tendency 
to  cut  down  the  use  of  the  more  expensive  forms  of 
medical  care  until  the  critical  stages  of  disease,  usually 
too  late  for  the  best  medical  efforts  to  yield  full 
results. 

THE  PSYCHOLOGICAL  LIMITATION 

People  have  inadequate,  false,  or  foolish  conceptions 
about  their  own  bodies  and  about  the  influences  which 
make   for  health   or   disease.      Different   levels    of 

396 


COMMUNITY  ORGANIZATION 

understanding  are  admirably  illustrated  among  immi- 
grants. 

To  the  primitive  mind,  healing  seems  a  form  of 
witchery  or  magic.  An  advertisement,  clipped  from 
a  Polish  newspaper,  read  as  follows: 

If  you  have  love  troubles,  write  me.  I  have  something 
that  never  fails.     Mrs.  Blank  .  .  .  Street. 

A  complaint  was  actually  received  by  one  of  the  staff 
of  this  study  through  the  editor  of  the  paper  in  which 
this  advertisement  appeared.  A  trusting  Pole  had 
read  the  advertisement,  and,  feeling  that  his  wife's 
affection  for  him  was  on  the  wane,  wrote  to  Mrs. 
Blank.  He  learned  that  for  $12  she  would  send  him 
a  love  potion  in  the  form  of  a  powder,  which,  put  into 
his  wife's  tea,  would  certainly  restore  his  happiness 
immediately.  He  sent  the  $12.  Unfortunately,  the 
package  arrived  in  the  absence  of  the  man  of  the  house, 
and  was  opened  by  his  wife.  She  threw  it  away,  and 
what  she  said  to  her  husband  he  failed  to  repeat  to 
the  editor.  He  did  not  lose  hope,  however,  but  again 
wrote  to  Mrs.  Blank,  telling  her  that  the  powder  had 
been  lost  through  accident  and  asking  her  to  send  him 
another.  She  refused,  but  after  more  correspondence 
agreed  to  send  a  second  package  for  an  additional  $6. 
By  this  time,  however,  the  man  had  become  disgusted 
and  complained  to  the  editor  of  the  paper  in  which 
he  had  seen  the  advertisement.  The  editor  seemed  to 
feel  rather  helpless  about  the  matter,  but  turned  the 
correspondence  over  to  us. 

Somewhat  less  primitive  is  the  reliance  on  medicine. 
Upon  still  another  level  is  the  conception  of  medical 

treatment  as  a  "system,"  according  to  which  each 

397 


IMMIGRANT  HEALTH  AND   COMMUNITY 

disease  has  certain  symptoms  which  are  dealt  with  in 
certain  ways  according  to  certain  rules  which  doctors 
know. 

The  patient's  failure  to  understand  the  doctor's 
work  may  be  almost  as  serious  a  limitation  upon  the 
efficiency  of  medical  treatment  as  lack  of  skill  in  the 
doctor  himself.  Only  the  most  patient,  tactful,  pains- 
taking course  of  explanations  and  instructions  can 
persuade  an  uneducated  adult  to  take  a  disagreeable 
treatment  or  to  change  his  occupation  or  many  of  his 
life  habits,  when  the  doctor  believes  that  his  health 
requires  one  or  all  of  these  things.  The  foreign  born 
are  by  no  means  the  only  people  who  do  not  under- 
stand the  principles  of  hygiene  and  the  nature  of  dis- 
ease; but  certain  points  due  to  this  lack  of  under- 
standing are  thrown  into  high  light  among  them. 

THE   PROFESSIONAL   LIMITATION 

Many  of  the  doctors,  hospitals,  and  dispensaries  acces- 
sible to  the  foreign  born  are  on  a  low  plane  of  efficiency. 
The  nature  of  the  private  doctor's  work  with  the 
foreign  born,  and  the  low  income  received,  tend  to 
draw  into  and  retain  in  immigrant  sections  physicians 
who  have  not  received  the  most  recent  or  best  medical 
training.  Severe  competition  often  prevails  which 
puts  a  premium  on  commercial  rather  than  on  pro- 
fessional ability,  and  tends  to  lower  rather  than  raise 
the  standard  of  medical  care. 

Medical  science  has  grown  beyond  the  mastery  of 
any  one  man  and  now  requires  specialization  of  skill. 
The  conditions  prevailing  in  immigrant  districts  prac- 
tically limit  the  physicians  who  reside  there  or  who  do 

398 


COMMUNITY  ORGANIZATION 

most  of  the  local  work,  to  general  practice.  I'he 
population  can  usually  gain  access  to  the  specialist 
only  by  going  to  hospitals  or  dispensaries  as  charity 
patients. 

The  practice  of  medicine  once  required  the  physi- 
cian's personality,  his  brain,  and  his  trained  eye  and 
hand,  and  only  a  few  simple  inexpensive  instruments 
for  diagnosis  and  treatment.  The  practice  of  medi- 
cine to-day  requires  an  elaborate  and  expensive  equip- 
ment— manifold  instruments.  X-ray  apparatus — and 
extensive  laboratory  service,  if  the  best  diagnostic 
and  therapeutic  results  are  to  be  achieved.  To  con- 
ceive that  such  equipment  could  be  available  to  every 
practitioner  in  his  private  office  under  his  individual 
control  is  out  of  the  question,  nor  could  any  one  man 
learn  to  use  all  of  it  if  he  had  it. 

There  are  various  exceptions  to  these  general  state- 
ments. Yet  in  the  main  they  are  true.  The  defect 
here  is  called  a  professional  one,  but  the  medical  pro- 
fession is  less  to  be  blamed  for  it  than  the  community. 

THE   SOCIAL  LIMITATION 

The  general  public  has  failed  to  keep  abreast  of  the 
development  and  possibilities  of  medical  service.  The 
practice  of  medicine  now  requires  community  aid  if 
the  physician  is  to  have  sufficient  capital  for  equip- 
ment and  sufficient  facilities  for  working  with 
specialists. 

The  organized  practice  of  medicine  appears  in  many 
hospitals  and  dispensaries  where  elaborate  equipment 
is  provided  which  many  doctors  can  use,  and  where 

the   different  branches   of  professional   skill  are   so 

399 


IMMIGRANT  HEALTH  AND  COMMUNITY 

organized  that  teamwork  and  group  medicine  are 
facilitated.  But  thus  far  such  organization  has  been 
only  within  the  limits  of  institutions,  to  which  a  com- 
paratively small  number  of  physicians  have  access, 
even  in  large  cities.  Specialists  are  few  in  number, 
except  in  large  cities,  and  high  priced. 

The  work  of  the  specialist  and  the  institution  is,  as 
a  rule,  inaccessible  to  the  immigrant  on  any  but  a 
charity  or  semicharity  basis.  The  need  of  a  com- 
munity organization  of  medical  service  which  shall 
be  exclusive  enough  to  provide  the  best  facilities  for 
medical  care  "to  all  the  people  who  need  them  and 
all  the  doctors  who  know  how  to  use  them"  is  as  yet 
nowhere  realized. 

We  see  the  need  of  such  community  organization 
most  strongly  in  the  small  city  or  town.  In  some  in- 
dustrial communities,  for  example,  where  from  50  per 
cent  to  90  per  cent  of  the  population  consists  of  foreign 
born  and  their  children,  there  is  only  one  hospital, 
and  that  hospital  is  chiefly  for  patients  who  can  pay. 
There  is  usually  no  dispensary,  and  most  important 
of  all,  only  a  very  small  proportion  of  the  doctors  of 
the  town  have  access  to  a  laboratory,  an  X-ray  de- 
partment, or  to  the  consultation  privileges  of  the  hos- 
pital staff.  There  are  few,  if  any,  specialists  in  a  small 
community,  for  there  are  rarely  enough  people  to 
support  a  skilled  oculist,  a  throat  and  ear  speciahst, 
an  orthopedist,  or  a  pediatricist. 

In  many  large  cities  the  sections  thickly  populated 

by  immigrants  suffer  under  the  same  conditions,  but  in 

the  large  city  better  facilities  can  be  obtained  by  going 

to  institutions  or  physicians  in  other  sections.    Only 

by  a  city -wide  organization  of  medical  service,  with 

400 


COMMUNITY  ORGANIZATION 

institutions  related  to  one  another  and  to  general 
medical  practice,  can  such  conditions  in  cities  be 
remedied.  Only  by  organization  on  a  state- wide  basis 
can  the  gross  deficiencies  of  the  small  cities  and  towns 
be  made  good. 

By  what  means  shall  the  extent  and  quality  of 
medical  care  among  the  immigrants  be  improved? 
Many  of  the  characteristics  of  our  present  system  of 
medical  service,  which  militate  against  the  immigrant, 
militate  also  against  the  native.  A  system  must  be 
developed  which  can  give  adequate  service  to  all 
people  of  small  means  and  little  health  knowledge. 
Given  this  fundamental  improvement,  farther  adap- 
tation to  the  needs  of  the  foreign  born  will  not  be 
difficult.  The  peculiar  terms  of  the  immigrants'  con- 
dition intensify  every  general  difficulty,  and  also 
create  special  problems,  but  dealing  with  these  is  a 
matter  of  technique,  the  specialized  application  of 
sound  general  principles. 

HEALTH   INSURANCE 

Health  insurance  is  one  measure  proposed  for  improv- 
ing the  medical  care  received  by  the  masses  of  the 
community.  It  is  aimed  particularly  at  the  economic 
limitation.  T\'Tiile  it  does  not  apply  separately  to 
the  foreign  born,  its  application  would  include  them. 
Health  insurance,  as  it  has  been  most  seriously  dis- 
cussed in  this  country,  follows  more  or  less  the  lines 
of  the  British  and  German  systems.  It  is  formulated 
most  definitely  in  the  so-called  Model  BiU  of  the 
American  Association  for  Labor  Legislation. 

The  provisions  of  such  a  law  require  that  all  wage 

401 


IMMIGRANT  HEALTH  AND  COMMUNITY 

earners — or  possibly  only  those  up  to  a  certain  limit 
of  income,  or  in  certain  occupations — be  insured.  In- 
surance groups  are  formed  along  local,  occupational, 
or  establishment  lines.  Existing  fraternal  or  indus- 
trial societies  can  thus  be  recognized.  The  insured 
pay  a  portion  of  the  expense,  the  employer  a  portion, 
and  the  state  may  also  pay  something,  either  directly 
or  by  meeting  the  overhead  expenses  of  administering 
the  system. 

Various  benefits  are  contemplated.  Cash,  amount- 
ing to  one  half  wages,  is  given  during  the  period  of 
sickness  up  to  twenty-six  weeks  in  one  year.  In  ad- 
dition, medical  care  is  provided  the  insured  person. 
Bills  which  have  been  considered  by  some  state  legis- 
latures give  medical  care  to  all  members  of  the  family. 
Some  of  the  bills  provide  for  dental  and  hospital  care, 
and  for  nursing  service;  some  for  a  maternity  benefit; 
and  most  for  a  small  cash  benefit,  not  exceeding  one 
hundred  dollars,  to  cover  the  immediate  funeral  ex- 
penses of  the  insured  person. 

Such  a  scheme  of  health  insurance  obviously  seeks 
to  prevent  the  expense  of  sickness  falling  upon  the 
individual  with  crushing  force  at  the  very  time  when 
he  and  his  family  are  least  able  to  bear  it.  The  pro- 
portion of  persons  who  are  ill  at  any  one  time  are 
cared  for  by  the  continued  payments  of  those  who  are 
well.  This  is  simply  the  application  of  familiar  prin- 
ciples of  insurance  long  established  in  other  fields. 
The  essential  idea  is  to  distribute  the  burden  of  a 
risk.  The  fundamental  virtue  of  the  proposal  is  that 
sickness  is  inherently  an  insurable  risk,  and  that  the 
burden  ought  to  be  distributed,  not  only  for  the  sake 
of  the  suffering  individual,  but  for  the  sake  of  the 

402 


COMMUNITY  ORGANIZATION 

community  as  a  whole,  which  in  the  long  run  has  to 
pay  the  bills  when  sickness  forces  families  below  the 
level  of  self-support. 

Many  of  our  immigrants  come  from  countries  in 
which  health  insurance  has  long  been  in  existence; 
moreover,  the  habit  of  co-operative  association  for 
mutual  benefit  is  much  more  highly  developed  among 
our  foreign-born  population  than  among  the  native. 
Health  insurance  should,  therefore,  be  peculiarly  ejffec- 
tive  in  the  case  of  the  foreign  born. 

Under  health  insurance  the  family  could  secure 
medical  service  without  incurring  a  heavy  financial 
burden.  Health  insurance,  however,  would  not  re- 
move the  psychological,  professional,  and  social  limi- 
tations upon  the  efficiency  of  medical  practice.  The 
patient's  ignorance  of  hygiene  and  of  how  and  when 
to  use  doctors,  would  not  be  directly  altered  by  health 
insurance.  The  insufficient  training  of  doctors,  the 
lack  of  equipment  and  of  opportunity  for  consulta- 
tion, are  faults  not  corrected  by  any  of  the  systems  of 
health  insurance  existing  abroad.  Some  of  the  bills 
proposed  in  this  country  mark  an  advance  in  this 
direction. 

The  system  of  medical  care  under  health  insurance 
ought  definitely  to  be  designed  to  provide  that  there 
shall  be  pooling  and  organization  of  medical  resources, 
and  not  merely  that  isolated  individual  practitioners 
shall  be  accessible  to  more  people.  Great  Britain 
made  the  mistake  of  fastening  upon  the  state  a  system 
of  medical  service  which  was  the  most  efficient  known 
in  the  middle  of  the  nineteenth  century,  but  which  is 
a  generation  or  more  behind  that  obtainable  in  the 
second  decade  of  the  twentieth.    Some  health-insur- 

403 


IMMIGRANT  HEALTH  AND  COMMUNITY 

ance  bills  recently  discussed  in  our  legislatures  would 
result  in  the  same  error. 

On  the  whole,  health  insurance  seems  to  be  the 
largest  single  step  that  can  be  taken  toward  reducing 
the  economic  limitations  upon  the  extent  and  quality 
of  medical  care  among  the  foreign  born.  But  it  will 
be  worth  while  to  delay  the  enactment  or  operation  of 
a  health-insurance  law  until  a  scheme  of  medical 
organization  can  be  included  that  will  remove  as  fully 
as  possible  the  other  limitations  upon  the  efficiency 
of  medical  care. 

COMMUNITY  ORGANIZATION  OF  MEDICAL  SERVICE 

Medical  service  should  be  organized  on  a  state  or 
community  basis.  This  would  mean  the  co-operation 
of  public  and  private  agencies  to  use  all  the  medical 
resources  of  the  community  to  the  best  advantage. 
It  is  desirable  that  we  have  higher  levels  of  education 
in  our  medical  colleges,  better  systems  of  licensing 
medical  practitioners  and  perhaps  of  supervising  them 
after  licensing.  Yet  these  measures  solve  only  part 
of  the  problem.  In  addition,  better  medical  facilities 
must  be  placed  at  the  command  of  the  practitioner, 
and  to  do  this  medical  facilities  must  be  organized  on 
a  community  basis. 

This  does  not  necessarily  mean  the  control  and  direc- 
tion of  medicine  and  the  employment  of  doctors  by 
the  state.  It  does  mean  recognition  by  public  authori- 
ties that  technical  facilities  for  diagnosis  and  treat- 
ment have  grown  beyond  the  point  where  the  average 
physician  can  possibly  provide  his  own.  The  public 
has  a  direct  interest  in  getting  good  doctoring.     It 

should  assist  financially  in  such  provision. 

404 


COMMUNITY  ORGANIZATION 

Such  a  general  community  plan  will  remove  the 
professional  and  social  limitations  upon  adequate 
medical  service.  It  is  probable  that  through  it  the 
psychological  limitation  can  finally  be  removed.  The 
process  of  education  must  work  its  slow  course.  The 
only  accelerator  is  the  adaptation  of  the  methods  of 
health  work  to  the  psychology,  the  backgrounds,  and 
the  characteristics  of  the  people  for  whose  benefit  the 
work  exists. 

Let  us  have  in  mind  that  a  program  of  medical  and 
health  service  to  a  community  is  not  a  program  of 
charity.  Only  a  narrow  and  inadequate  conception 
of  such  service  limits  it  to  the  poor  or  to  any  special 
section  of  the  community,  such  as  the  foreign  born. 
Special  adaptation  in  policy  or  method  of  work  to 
the  peculiar  needs  of  certain  sections,  such  as  the  for- 
eign bom,  is  wise  and  right,  but  the  scope  of  the 
service  as  a  whole  should  be  broader  than  any  section. 
The  more  that  medical  and  health  facilities  are  used 
by  many  social  classes,  the  easier  it  will  be  to  main- 
tain a  high  standard  and  secure  sufficient  appro- 
priations. 

THE  LOCALIZATION  OF  HKA.LTH  WORK 

One  of  the  primary  considerations  in  a  community 
plan  is  the  localization  of  health  work,  the  units  of 
area  or  population  selected  for  service,  or  for  recruit- 
ing personnel  and  finances. 

In  the  health  center  established  in  New  York  City 
by  the  Department  of  Health  in  1915,  25,000  Jewish 
people  were  included  in  the  health  district.  This 
population,  however,  was  living  in  tenement  houses, 

mostly  five  stories  high,  with  four  families  to  a  floor, 
27  405 


[MMIGRANT  HEALTH  AND  COMMUNITY 

30  that  the  whole  area  of  the  district  was  less  than 
one  eighth  of  a  square  mile.  Under  such  conditions 
it  is  necessary  to  use  a  smaller  unit  of  area  and  a  much 
larger  unit  of  population  than  in  such  a  town  as 
Framingham,  Massachusetts,  with  two  thirds  the 
population.  The  district  selected  by  the  Social  Unit 
in  Cincinnati  has  a  population  of  15,000  living  in 
small  houses.  The  area  covered  is  perhaps  six  times 
that  of  the  New  York  health  district,  with  only  about 
60  per  cent  of  the  population. 

In  outlining  the  boundaries  of  a  district  racial  lines 
may  have  to  be  taken  into  consideration.  For  exam- 
ple, there  are  localities  in  which  the  population  of  one 
nativity  stops  suddenly  at  certain  streets,  and  it  may 
be  wiser  to  have  a  district  of  fairly  homogeneous  popu- 
lation than  one  containing  two  race  groups.  The 
number  of  the  population,  the  degree  of  congestion, 
the  race  constitution,  the  existing  political  boundaries, 
such  as  wards  or  precincts,  and  finally  the  topography, 
must  all  be  taken  into  consideration  in  determining 
the  unit  within  which  a  health  center  is  to  work.  The 
size  of  the  staff  will  depend  upon  the  population  and 
area. 

GENERALIZATION   IN   FIELD   WORK 

The  selection  of  small  units  for  health  service  has 
raised  the  problem  of  so-called  "generalization"  in 
field  work.  In  this  sense  generalization  means  the 
performance  of  several  functions  by  a  single  worker. 
Thus,  instead  of  infant-welfare  work  and  antituber- 
culosis work  being  conducted  each  by  a  separate  corps 
of  nurses  within  the  same  district,  one  nurse  with  a 

smaller  district  carries  on  both.    Historically  the  de- 

406 


COMMUNITY  ORGANIZATION 

velopment  of  health  work  in  the  United  States  was 
through  the  establishment  of  one  specialty  after 
another.  The  movement  toward  generalization  thus 
tends  to  break  some  established  lines.  Does  anti- 
tuberculosis work  suffer  in  quality  if  a  nurse  also  does 
infant  work,  or  bedside  nursing,  or  school  nursing,  or 
all  these  .5^ 

The  extent  to  which  generalization  is  practicable  is 
a  question  of  degree,  which  will  not  be  answered  alike 
in  all  communities.  Success  in  generalization  depends 
very  largely  upon  the  people  who  are  doing  the  work. 
A  higher,  not  a  lower,  degree  of  skill  and  personality 
are  necessary  in  the  generalized  worker,  compared 
with  the  specialist.  Many  of  the  experiments,  and  the 
extension  of  almost  all  of  them,  wait  upon  securing  a 
sufficient  number  of  competent  persons. 

A  large  proportion  of  local  health  centers  have  been 
in  districts  particularly  foreign  in  population.  Our 
survey  has  perhaps  made  it  clear  that  the  less  familiar 
the  people  are  with  American  conditions  and  with  the 
technical  phases  of  medical  and  health  service,  the 
more  attention  must  the  health  worker  pay  to  the 
human  and  personal  elements. 

In  general,  it  may  be  said  that  the  less  knowledge 
of  medical  and  health  matters  the  people  have,  the 
more  should  the  worker  have.  It  requires  more,  and 
not  less,  tact  and  training  to  explain  the  care  of  a 
baby  to  an  ignorant  mother  than  to  an  intelligent 
mother.  The  simpler  the  type  of  mind  that  is  to  be 
dealt  with,  the  simpler  and  more  elementary  must  be 
the  terms  of  the  message.  The  most  obvious  and 
elementary  points  are  often  those  of  greatest  impor- 
tance, and  most  of  these  obvious  and  elementary  points 

407 


IMMIGRANT  HEALTH  AND  COMMUNITY 

are  very  similar  in  all  forms  of  medical  and  health 
work. 

Generalization,  therefore,  throwing  emphasis  upon 
the  personal  instead  of  the  technical  elements,  is  par- 
ticularly applicable  to  work  among  the  foreign  born, 
provided  always  that  we  have  workers  with  the  nec- 
essary qualifications.  Medical  and  health  work  with 
the  foreign  born  places  an  emphasis  upon  personality 
and  upon  understanding  of  people,  more  than  upon 
skill  in  technique,  and  only  through  personality  and 
understanding  of  the  people  can  results  in  technique 
be  realized. 

SERVICE  ORGANIZATION 

The  unit  of  area  selected  for  field  work  should  not  be 
the  same  as  the  area  from  which  professional  services 
are  to  be  drawn.  A  much  larger  unit  of  population  is 
necessary  to  supply  all  the  various  facilities  and  per- 
sonnel which  are  included  in  a  complete  medical  and 
health  service.  The  Social  Unit  in  Cincinnati  has  pro- 
ceeded as  if  the  personnel,  at  least  for  the  medical 
service,  must  be  drawn  from  within  the  same  area  as 
that  selected  for  field  work.  Proceeding  on  this  theory, 
specialists  in  pediatrics  and  obstetrics,  for  example, 
could  not  be  included.  In  selecting  the  nonmedical 
personnel,  such  as  the  nurses,  this  theory  was  not 
applied. 

In  the  Framingham  Community  Health  and  Tuber- 
culosis Demonstration  this  mistake  has  been  avoided, 
and  outside  physicians  have  been  brought  in  to  see 
patients  at  the  request  of  local  physicians  or  at  the 
patient*s  own  desire.    As  a  result,  the  physicians  of 

the  community  are  provided  with  expert  consultants 

408 


COMMUNITY  ORGANIZATION 

without  interference  with  their  practice,  and  the  people 
receive  a  quality  of  service  which,  under  ordinary 
conditions,  would  not  be  available  to  them. 

All  the  factors  necessary  to  a  complete  medical  and 
health  service  ought  to  be  available  for  every  neigh- 
borhood in  every  area  of  a  community  or  of  a  state. 
The  professional  personnel  of  the  neighborhood  must 
not  be  the  sole,  or  the  determining,  factor,  but  a  co- 
operating element  in  the  organization  of  professional 
services. 

In  many  small  cities  and  towns  there  is  a  sort  of 
local  self-consciousness,  or  pride,  which  renders  it 
difficult  to  include  so-called  outside  talent  in  the 
service  organization.  A  very  worthy  human  sentiment 
is  at  the  basis  of  this  feeling,  but  a  thorough  under- 
standing that  the  community  can  secure  satisfactory 
service  only  if  a  broader  area  is  drawn  upon  will  go 
far  to  render  the  right  plan  practicable.  This  is 
especially  important  in  case  of  the  emergency  needs  of 
epidemic  or  disaster. 

The  right  kind  of  service  organization  includes 
specialists,  e.g.,  oculists,  orthopedists,  psychiatrists, 
experts  in  the  diagnosis  of  tuberculosis,  who  visit  the 
appropriate  clinics  in  the  community  just  so  often  as 
is  necessary.  A  small  town  may  require  one  half  or 
the  whole  of  a  dentist's  time  for  the  school  children, 
or  for  the  public  in  general.  Psychiatrists  for  a  mental 
clinic  would  be  needed  by  the  same  community  only 
once  a  month  or  even  less  often.  The  nature  of  the 
work,  or  the  relative  frequency  of  the  particular  dis- 
eases in  a  population,  determines  the  time  required 
from  different  consultants  and  specialists. 

The  service  organization  must  include  state  as  well 

409 


IMMIGRANT  HEALTH  AND  COMMUNITY 

as  local  or  county  personnel  and  functions.  The  ex- 
perts or  the  district  supervisors  of  the  state  health 
department  should  furnish  organizing  ability  and  a 
standardizing  influence.  We  have  good  examples  of 
this  in  the  administration  of  the  venereal-disease 
program  in  a  number  of  states  during  and  since  the 
war. 

Health  literature  for  use  in  clinics  and  in  the  homes 
can  be  more  efficiently  and  economically  prepared  by 
a  state  or  national  organization  than  by  each  local 
community  for  itself.  The  diagnostic  facilities  of  a 
state  laboratory  should  be,  as  they  are  in  many  states 
to-day,  made  available  to  physicians  and  clinics  in 
every  community.  Expensive  equipment,  such  as 
an  X-ray  outfit,  should  be  provided  for  such  an  area 
or  population  as  can  utilize  it  fully.  So  should  a 
hospital,  or  a  dispensary,  with  all  its  varied  diagnostic 
and  therapeutic  apparatus. 

DISTRIBUTION   OF   THE   FINANCIAL   BURDEN 

The  expense  of  health  work  must  be  distributed  over 
an  area  sufficiently  large  to  equalize  local  resources 
with  local  needs.  Whereas  the  need  for  medical  and 
health  work  is  almost  exactly  in  proportion  to  the 
number  of  the  population,  the  financial  resources  of 
an  area  are  not  by  any  means  determined  by  the 
number  of  people  living  in  it.  The  financial  power  or 
tax-paying  ability  of  an  industrial  city  or  a  well-to-do 
residential  suburb  may  be  many  times  greater  than 
that  of  large  rural  areas,  including  an  equivalent 
population.  Yet  the  interests  of  the  city  in  the  pre- 
vention of  disease,  the  promotion  of  a  wholesome  life 

410 


Jnterpreter5 


•Good* 
•lConnmunity-VJbrkeri3; 


Good-riouies" 


COMMUNITY   EQUIPMENT   FOR   HEALTH   EDUCATION 


IMMIGRANT  HEALTH  AND  COMMUNITY 

for  the  state  as  a  whole,  and  of  industrial  efficiency  in 
the  workers,  give  its  residents,  its  business  men,  and 
its  taxpayers  a  direct  interest  in  better  medical  and 
health  service  for  the  country  and  the  state. 

It  is  proper  and  fitting  that  the  local  community 
organization  should  bear  the  primary  financial  re- 
sponsibility of  local  medical  and  health  service,  but 
a  larger  area  (sometimes  the  county,  sometimes  the 
state,  perhaps  the  Federal  government)  may  well 
share  certain  expenses.  The  venereal-disease  cam- 
paign, financed  in  part  by  national  and  in  part  by 
local  funds,  and  the  work  of  vocational  education, 
financed  partly  by  state  and  partly  by  national  funds, 
have  begun  to  make  the  application  of  this  principle 
familiar  to  the  people  at  large. 

The  organi^ied  use  of  hospitals  in  one  community 
by  those  in  smaller  neighboring  communities  or  rural 
areas,  is  now  possible,  with  the  development  of  motor 
transportation.  The  possibilities  of  transportation 
make  very  small  hospital  units  (twenty  beds  or  less) 
rarely  necessary,  because  larger  units,  better  equipped 
and  more  economically  administered,  can  be  used  not 
only  for  obstetrical  and  all  forms  of  emergency  service, 
but  for  general  medical  and  surgical  work  as  well. 
Small  local  units  are  necessary  in  most  instances  only 
as  first  aid  or  temporary  relief  stations. 

The  provision  of  nurses  is  properly  a  function  of 
the  local  organization,  but  state  or  county  aid  should 
be  provided  in  organizing  nursing  service  and  in 
standardization  and  general  supervision  of  its  work. 
It  would  be  an  appropriate  and  requisite  health  meas- 
ure for  some  states  to  subsidize  visiting-nursing  service 

in  certain  sections. 

412 


COMMUNITY  ORGANIZATION 

Just  as  local  areas  may  combine  to  render  their 
hospital  and  clinic  service  more  efficient,  so,  as  has 
often  been  suggested,  the  combination  of  areas  to 
employ  a  full-time  health  officer  is  much  to  be 
encouraged. 

In  communities  having  a  large  proportion  of  foreign 
born,  the  special  difficulties  of  overcoming  the  barriers 
of  language,  and  social  and  racial  cleavage,  are  often 
so  great  that  special  assistance  is  necessary.  This 
assistance  might  take  the  form  of  trained  personnel 
loaned  to  deal  with  the  particular  race  groups  of  the 
locality  or  to  start  the  local  people  on  the  right 
methods ;  or  it  might  be  a  financial  subvention  as  such, 
to  be  administered  by  the  community  organization 
with  some  supervision  or  advisory  aid  from  the  larger 
area.  The  state  or  national  government,  or  such  a 
body  as  the  Red  Cross,  might  provide  this  assistance. 

No  large  city  would  tolerate  the  notion  that  each 
ward  should  pay  by  itself  for  its  own  public  schools. 
The  wards  that  need  the  best  service  would  in  many 
cases  have  the  poorest  schools.  The  same  principle 
holds  when  we  compare  the  large  cities  with  the 
small  towns  and  rural  communities  of  the  state. 
Communities  are  even  more  immediately  interde- 
pendent in  relation  to  the  spread  of  disease  than  in 
matters  of  education.  The  state,  as  a  whole,  must 
be  brought  to  recognize  the  interest  of  all  its  parts 
in  the  health  of  every  member,  and  to  equalize  the  dis- 
tribution of  the  financial  burden. 

PARTICIPATION  BY  THE   COMMUNITY 

With  the  people  of  the  town  or  city  or  district  must 
rest  the  demand  for  service,  the  decision  as  to  what 

413 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  service  shall  be,  and  the  general  policies  under 
which  it  shall  be  provided.  Any  other  program  is 
neither  democratic  in  theory  nor  practicable  under 
American  conditions.  Except  in  times  of  emergency, 
such  as  epidemic  or  disaster,  the  state  should  not  take 
initiative  or  authority  out  of  the  hands  of  the  locality. 

On  the  other  hand,  it  is  essential  that  the  locality 
shall  be  brought  to  recognize  its  own  needs  and  that 
these  needs  cannot  be  met  unless  the  organization 
through  which  service  is  to  be  provided  is  more  com- 
prehensive in  material  facilities  and  personnel  than 
the  local  community  itself  can  usually  furnish.  This 
is  the  first  educational  task  to  be  undertaken.  The 
educational  method  that  leads  to  success  is  partly 
through  the  written  and  personal  presentation  of 
facts,  but  largely  through  beginning,  step  by  step,  to 
provide  services  for  which  there  is  a  demand. 

This  is  an  easy  principle  to  perceive  and  a  difficult 
one  to  apply.  It  is  much  easier  for  the  professional 
workers  to  make  their  own  plan  and  carry  it  out  for 
a  city  or  a  district,  than  it  is  to  consult  the  people 
who  are  served.  Yet,  in  the  long  run,  the  best  under- 
standing of  medical  and  health  work,  and  the  maxi- 
mum results  in  health  education,  can  only  be  secured 
by  a  process  in  which  the  people  participate. 

In  private  health  organization,  such  as  the  tuber- 
culosis committee  or  the  visiting  nurses'  association, 
the  board  of  trustees  represents  the  lay  public  and 
supplies  the  needed  balance  for  the  professional  work- 
ers. But  such  boards  of  trustees  rarely,  if  ever,  repre- 
sent the  people  who  are  served.  In  public  organiza- 
tions, such  as  a  health  department,  the  mayor  or  town 

council  represents  the  public  and  is  nearer  to  the 

414 


COMMUNITY  ORGANIZATION 

average  man's  point  of  view  than  is  the  average  board 
of  trustees.  But  there  is  needed  in  addition,  in  either 
private  or  public  organization,  some  group  represent- 
ing the  people  who  are  served.  This  idea  h-as  been 
most  fully  worked  out  in  the  Cincinnati  Social  Unit. 

The  principle  of  co-operation  is  particularly  impor- 
tant in  health  work  with  the  immigrants.  It  can  be 
achieved  directly  or  through  representatives,  who 
stand  between  the  professionals  and  the  laymen  and 
help  to  interpret  one  to  the  other.  As  a  rule,  the  most 
ready  means  of  securing  direct  contact  with  immi- 
grants and  co-operation  from  them  is  through  leaders 
of  various  races  or  organizations. 

The  priest  is  often  a  most  important  helper.  For- 
eign-born business  men,  oflBcials  of  immigrant  benefit, 
fraternal  or  nationalistic  societies,  are  usually  to  be 
found  in  any  community  or  district  where  there  are 
many  foreign  born.  The  foreign-born  doctor  has  been 
discussed  at  considerable  length  in  preceding  chapters. 
The  extent  to  which  medical  and  public-health 
agencies  can  secure  and  utilize  co-operation  from  him, 
depends  chiefly  upon  the  individual.  At  least,  it  is 
wise  to  secure  sufficient  contact  with  the  foreign  doc- 
tors of  a  community  or  neighborhood  to  decide  how  far 
their  co-operation  or  their  actual  participation  in  certain 
medical  or  health  work  will  be  wise  and  practical. 

The  local  health  center  or  clinic  may  develop  a  local 
neighborhood  organization.  Usually  it  is  not  difficult 
to  start  health  committees  or  general  citizens'  com- 
mittees; it  is  difficult  to  keep  up  continued  interest 
and  activity  on  the  part  of  such  groups.  If  co~ 
operating  committees  of  the  foreign-born  people  in 

a  neighborhood  are  to  be  not  only  organized,  but  kept 

415 


IMMIGRANT  HEALTH  AND  COMMUNITY 

active  and  continuously  helpful,  properly  trained  peo- 
ple must  devote  a  considerable  amount  of  time  to 
this  task. 

It  is  often  a  question  whether  it  is  wise  to  develop 
special  health  committees  in  a  small  neighborhood. 
The  problems  are  usually  technical,  and  after  certain 
general  questions  of  policy  have  been  discussed,  there 
seems  little  for  the  committee  to  do.  Where  it  is 
possible  for  a  local  committee  to  have  general  civic 
functions,  a  variety  of  different  interests  on  the  part 
of  the  members  can  be  appealed  to.  By  the  time  that 
one  question  has  been  worked  out  another  in  a  different 
sphere  has  arisen.  Thus  any  neighborhood  organization 
for  co-operative  medical  and  health  work  can  best  be 
made  part  of  the  general  civic  organization,  a  local 
Community  Council,  for  example. 

The  question  also  arises  whether  it  is  better  to  have 
one  central  organization  in  a  community  rather  than 
a  chain  of  neighborhood  organizations.  In  many 
communities  of  moderate  size  a  certain  number  of 
immigrant  leaders  could  be  found  who  would  be 
valuable  advisers  for  the  medical  and  health  work, 
and  who  would  help  on  many  other  local  problems. 
Unless  it  is  clear  that  sufficient  time  and  effort  can 
be  devoted  by  trained  people  to  keeping  up  a  number 
of  neighborhood  organizations,  it  will  often  be  better 
to  have  a  central  community  organization,  bringing 
in  the  chief  elements  among  the  foreign  born.  It  is, 
of  course,  desirable  to  have  both  if  circumstances 
justify  it. 

In  general,  the  practical  steps  to  take  are: 

First:  Informal  contacts  with  immigrant  leaders' of 

various  groups. 

416 


COMMUNITY  ORGANIZATION 

Second:  The  organization  of  these  on  a  general 
community  basis,  as  part  of  a  general  Community 
Council,  or  as  an  Americanization  committee,  or  as  a 
separate  health  committee,  if  there  is  sufficient  special 
interest  to  warrant  that. 

Third:  The  development  of  local  neighborhood 
committees  affiliated  with  or  independent  of  the  cen- 
tral body,  according  to  conditions. 

In  some  cities  the  so-called  Americanization  pro- 
gram has  developed  just  such  community  commit- 
tees.   The  Cleveland  Americanization  Committee  fur- 
nishes an  excellent  illustration  of  this.    Such  a  central 
body  can  be  of  service  to  all  types  of  medical  and 
health  work,  from  local  health  centers  to  large  hos- 
pitals.   Not  only  can  the  members  of  such  a  central 
committee  be  directly  useful,  but  they  can  assemble 
local  groups  of  their  own  people  when  necessary,  or 
help  in  forming  local  organizations.     Such  a  general 
committee  is  in  a  position  to  assist  every  locality  in 
building  up  co-operation  between  local  professional 
workers  and  the  people  of  any  race  in  that  district. 
It  is  difficult  to  arouse  and  maintain  co-operation 
between  the  residents  of  a  district,  a  town,  or  a  city, 
and  the  professional  workers  who  come  to  render 
definite  services.    The  difficulty  of  this  task  must  be 
recognized,   but   its   fundamental   importance   must 
never  be  forgotten.     At  bottom,  it  is  the  task  of 
realizing  democracy. 

PREVENTIVE  MEDICINE  FOSTERED  THROUGH  CURATIVE 

A  program  of  community  health  work  is  particularly 
adapted  to  promoting  preventive  work  as  well  as 

417 


IMMIGRANT  HEALTH  AND  COMMUNITY 

curative.  Preventive  medicine  is  free  from  the  com- 
mercial element  and  applies  to  all  individuals  in  a 
community,  native  and  foreign  born  alike.  For  this 
reason  it  is  very  suitably  a  public  function. 

There  is  a  great  psychological  obstacle,  however, 
to  preventive  work  with  the  foreign  born.  When  an 
immigrant  is  suffering,  he  is  ready  to  seek  care.  But 
to  approach  a  well  man  or  woman  with  excellently 
intended  hygienic  advice  is  a  difficult  proposition.  It 
is  a  sound  principle,  borne  out  again  and  again  by  this 
study  of  the  foreign  born,  that  curative  medicine  pro- 
vides an  approach  to  preventive.  Our  goal  is  to  teach 
people  how  not  to  get  sick,  "how  to  be  healthy  and 
well."  But  we  generally  find  that  the  best  way  to  get 
this  instruction  accepted  and  put  into  practice  by  the 
recipient  is  to  give  it  when  the  recipient  or  some 
member  of  his  family  is  sick  or  threatened  with 
sickness. 

When  we  are  dealing  with  people  of  such  advanced 
education  and  consequent  openness  and  flexibility  of 
mind  that  they  will  receive  from  any  competent  au- 
thority instructions  in  hygiene,  in  the  care  of  children, 
in  the  prevention  of  infection,  and  put  them  into 
practice  without  prejudice  or  hesitation,  then  our 
method  of  approach  can  be  neglected,  and  the  pure 
light  of  science  need  be  the  only  guide  of  the  public- 
health  worker.  But  in  dealing  with  our  immigrants 
or  other  persons  whose  previously  formed  habits  or 
prejudices  are  strong  and  definite,  and  whose  circum- 
stances may  not  permit  an  easy  conformity  to  ideal 
hygienic  conditions,  then  our  method  of  approach  is 
of  fundamental  importance  if  we  are  to  expect  prac- 
tical results  from  our  efforts  toward  prevention. 

418 


COMMUNITY  ORGANIZATION 

That  curative  work  furnishes  the  best  approach  to 
preventive  has  been  fully  recognized  in  the  practice 
of  most  organizations  carrying  on  extensive  field  work. 
This  is  notably  true  in  visiting  nursing.  The  original 
work  of  the  nurse  was  at  the  bedside.  What  she 
brings  in  womanly  sympathy  and  in  professional  skill 
are  two  offerings  which  it  requires  no  interpreter  to 
make  clear  to  the  crudest  intelligence  when  acute 
sickness  is  in  the  home.  The  recent  influenza  epidemic 
brought  this  out  in  a  dramatic  way.  Much  testimony 
was  secured  from  immigrants,  from  physicians,  and 
from  nurses  during  the  winter  following  the  1918  epi- 
demic that  the  nurse  who  went  into  the  homes  during 
those  desperate  weeks  to  give  sorely  needed  service, 
had  an  approach  to  the  family  and  won  a  sympathy 
which  furnished  a  splendid  basis  for  purely  educa- 
tional work. 

In  the  field  of  preventive  medical  and  health  work, 
therefore,  we  see  that  there  is  particular  need  for  em- 
phasizing our  initial  principle  that  the  study  of  people 
must  run  parallel  to  the  study  of  technique.  As  a  cor- 
ollary to  this,  curative  work  must  be  connected  with 
preventive  work,  so  that  the  service  which  the  people 
seek  of  their  own  initiative  can  be  supplemented  by 
the  service  which  we  believe  the  larger  interests  of  all 
require.  Give  a  man  what  he  wants  when  he  wants 
it,  and  he  will  be  ready  to  take  what  he  needs  when 
you  offer  to  give  it. 

A  SMALL   COMMUNITY   PROGRAM 

The  objection  is  often  raised  that  community  pro- 
grams for  health  are  too  often  adapted  only  to  the 

419 


IMMIGRANT  HEALTH  AND  COMMUNITY 

large  city,  where  there  are  many  health  agencies  and 
abundant  financial  resources^  while  it  is  often  the 
small  community  that  is  most  in  need  of  a  compre- 
hensive health  program.  Since  half  of  our  population 
live  in  villages  or  rural  districts,  and  more  than  70 
per  cent  in  communities  of  50,000  or  less,  too  much 
thought  cannot  be  spent  in  considering  the  small  com- 
munity's health  problem.  The  large  city  has  been 
the  experiment  station  for  technique,  where  methods 
in  school  work,  health  work,  recreation,  and  countless 
other  human  activities  have  been  initiated  and  tried 
out.  The  small  community  is  the  place  where  these 
policies  and  methods  must  be  applied  if  they  are  to 
reach  the  mass  of  the  people. 

The  foreign  born,  too,  are  frequently  regarded  as 
a  problem  of  the  large  city  exclusively.  It  is  true  that 
New  York,  the  great  port  of  entry  for  immigrants, 
has  gathered  its  millions  of  foreign  born  and  their 
children,  and  that  other  cities  receive  them  in  large 
numbers. 

But  some  important  race  groups,  notably  the  Scan- 
dinavians, have  settled  primarily  in  rural  areas  and 
small  towns.  An  increasing  number  of  the  Italians, 
Poles,  and  other  Slavic  peoples  have  moved  to  the 
country,  where  the  agricultural  life  to  which  they  have 
been  accustomed  abroad  can  be  resumed. 

It  is  even  more  common  to  find  the  immigrant  in 
the  industrial  community  of  moderate  size.  For  most 
of  the  heavier  and  less  skilled  kinds  of  work  in  manu- 
facturing and  mining,  we  have  come  to  depend  so 
largely  upon  immigrant  labor  that  an  enormous  emi- 
gration of  the  foreign  born  to  these  middle-sized  com- 
munities has  taken  place. 

'    420 


COMMUNITY  ORGANIZATION 

There  is  no  inherent  reason  why  the  principles  dis- 
cussed here  cannot  apply  to  a  community  of  any  size. 
As  a  matter  of  fact,  it  is  in  a  small  place  that  the  most 
comprehensive  plan  yet  made  has  been  tried  out.  "A 
program  of  clinical  activities  for  towns  of  approxi- 
mately 20,000  population  "  was  worked  out  in  1918 
for  the  Committee  on  Dispensary  Work  of  the  Ameri- 
can Hospital  Association,  by  Dr.  Donald  B.  Arm- 
strong, the  executive  officer  of  the  Framingham  Com- 
munity Health  and  Tuberculosis  Demonstration.^ 
Step  by  step  he  has  put  it  into  actual  practice  in 
Framingham.    A  portion  of  the  plan  is  reprinted  here: 

Essential  Objects 

The  essential  objects  in  the  development  of  any  clinic 
program  in  such  a  commmiity  would  include  encouraging 
the  town  to  recognize  its  medical  and  health  clinic  needs 
and  to  try,  through  public  and  private  channels,  to  meet 
these  needs.  This  would  probably  involve  the  definitizing 
of  opportunities  for  community  service.  The  hospitals 
and  other  existing  treatment  agencies  should  be  encouraged 
to  see  the  community  as  a  whole  and  not  to  deal  exclusively 
with  individual  cases.  It  is  essential  to  protect  the  hospital 
and  therapeutic  facilities  by  a  bulwark  of  clinical  agencies, 
thereby  heading  off  many  potential  patients  from  hospital 
treatment  by  means  of  education,  preventive  advice,  and 
early  treatment  of  incipient  conditions.  These  clinics 
should  serve  primarily  to  decrease  the  need  for  hospital 
treatment,  and  not  primarily  as  an  avenue  into  the  hospital. 

The  clinic  service  should  be  put  on  a  self-respecting,  self- 
supporting  basis,  thereby  encouraging  adequate  medical 
attention  to  the  class  of  individuals  who  fall  between 
the  very  poor  and  the  very  wealthy.     The  result  would  be  a 

^Donald  B.  Armstrong,  M.D.,  "Program  for  Clinical  Activities 
for  Towns  of  Approximately  Twenty  Thousand  Population," 
The  Modern  Hospital,  vol.  xii,  no.  3,  March,  1919. 

28  421 


IMMIGRANT  HEALTH  AND  COMMUNITY 

consequent  improvement  of  medical  practice  in  general, 
with  its  elevation  and  standardization. 

Community  Needs 

The  clinic  needs  of  a  community  of  this  size  are  in  general 
as  follows:  (1)  preventive,  educative,  health  creative; 
(2)  disease  detective,  eliminative,  suppressive;  (3)  curative, 
therapeutic. 

Program  for  Meeting  These  Needs 

The  hospitals  of  a  small  community  are,  together  with 
the  health  department,  its  chief  centers  of  organized 
service  for  health.  The  provision  of  clinics  for  a  com- 
munity should  be  based  upon,  or  at  least  closely  connected 
with,  its  hospital  or  hospitals.  The  hospitals  have  medical 
equipment  and  often  have  space  which  can  be  used  for 
clinics  with  great  advantage. 

The  practical  clinic  needs  of  a  community  fall  into  two 
classes:  (1)  clinics  for  public  health  work,  and  (2)  clinics 
for  diagnosis  and  treatment.  The  two  groups,  however, 
overlap  considerably  in  their  practical  operation,  both  as 
to  machinery  and  field. 

The  public  health  clinics  grow  out  of  the  demand  upon 
the  health  department  to  meet  the  medical  needs  of  a 
community.  The  clinics  for  diagnosis  and  treatment  grow 
out  of  the  demand  upon  the  hospital  to  meet  the  same  needs. 
By  co-operation  of  the  hospitals  with  the  health  department, 
or  such  voluntary  agencies  as  tuberculosis  committees,  and 
by  co-ordination  of  the  actual  work  done  by  all  these 
agencies,  the  most  ejficient  service  will  be  secured  with  the 
greatest  economy. 

I.  Public  Health  Clinics 

1.  Prenatal  and  Infant  Work. — In  the  establishment  of 
infant  clinics  in  a  small  city  the  essential  considerations  are 
at  least  in  part  as  follows: 

The  work  should  be  designed  to  reach  both  sick  and  well 
babies,  should  be  partly  therapeutic  (in  co-operation  with 
local  physicians  and  institutions),  and  should  be  largely 

422 


COMMUNITY  ORGANIZATION 

educational,  covering  the  needs  of  infant  hygiene,  feed- 
ing, etc. 

In  most  communities,  infant  clinics  may  be  essentially 
educational  and  consultation  establishments;  in  some 
places  they  may  also  be  milk  stations. 

The  work  should  be  associated  with  infant  -  welfare 
nursing,  both  prenatal  and  postnatal  in  character,  and  a 
prenatal  clinic  for  the  examination  and  advice  of  expectant 
mothers  should  be  closely  associated  with  the  infant- welfare 
clinic  whenever  possible. 

While  the  clinics  themselves  are  essential  for  consulta- 
tions and  publicity,  they  are,  perhaps,  from  a  practical 
point  of  view,  less  important  than  the  home  nursing  and 
advice  associated  with  clinic  work.  Constant  medical 
attention  is  essential  at  the  clinics,  with  expert  pediatric 
and  obstetrical  medical  advisory  service  in  difficult  cases. 
The  medical  service  should  be  paid  for.  The  clinics  may 
possibly  be  made  partly  self-supporting. 

These  clinics  may  be  held  in  school  buildings,  community 
centers,  etc.,  and  should  number  from  two  to  four  for  a 
community  of  this  size,  being  held  weekly  in  each  neigh- 
borhood. One  prenatal  clinic  a  week  will  usually  be  suf- 
ficient. Preferably,  the  infant  -  welfare  work  should  be 
under  the  auspices  of  the  town's  official  health  agencies, 
though  it  may  be  established  under  private  auspices. 

2.  The  Preschool  Period — From  a  practical  point  of  view 
it  is  somewhat  artificial  to  consider  this  age  group  separately. 
Ordinarily,  the  needs  of  this  group,  particularly  in  a  small 
city,  can  be  met  by  the  infant  or  school  health  machinery. 
Important  points  for  this  group  are: 

The  work  should  pay  special  attention  to  educational 
hygiene,  feeding,  and  nutrition,  the  detection  and  elimina- 
tion of  physical  defects,  etc. 

The  tuberculin  testing  of  large  groups  of  children  in  this 
age  group  will  throw  light  on  the  prevalence  of  infection, 
may  indicate  the  need  for  special  measures,  may  emphasize 
the  need  for  milk  pastuerization,  and  will  furnish  valuable 
scientific  data  regarding  the  probable  age  at  which  tubercu- 
losis infection  ordinarily  occurs. 

423 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Work  in  this  group  should  be  under  the  auspices  of  the 
community's  health  authorities  and  may  be  supervised  by 
the  board  of  health  or  the  school  committee,  depending 
upon  the  arrangement  in  the  particular  community. 

This  work,  as  well  as  that  with  the  school  children,  may 
well  be  associated  with  summer  health-camp  activities  and 
in  most  communities  be  made  partly  self-supporting. 

3,  The  School  Period. — This  work  must  be  of  necessity 
both  diagnostic  and  therapeutic  in  character.  The  work 
of  examining  and  detecting  disease  or  defect  is  done  partly 
in  the  school  and  partly  in  the  clinics.  The  curative  work 
is  primarily  for  the  clinics.  This  service  should  be  closely 
allied  with  the  health  educational  work  in  the  schools  along 
other  lines,  the  recreation  and  athletic  work,  the  hygiene 
instruction  of  both  pupils  and  teachers,  the  physical  edu- 
cational activities,  the  open-window  room  work,  the  school- 
lunch  provision,  etc.  The  staff  for  a  town  of  this  size  would 
include  a  full-time  physician,  two  full-time  nurses,  and  such 
specialists  as  can  be  provided  in  the  clinics.  A  dentist  is 
particularly  needed. 

There  should  be  at  least  one  central  dental  clinic  connected 
with  the  main  clinic  for  diagnosis  and  treatment,  and 
there  should  be  substations,  if  possible,  established  in  school 
buildings,  community  centers,  or  factories.  In  the  evening 
the  facilities  should  be  open  to  the  public  on  a  pay  basis 
under  other  auspices,  perhaps,  than  the  board  of  health  or 
school  committee. 

An  eye-refraction  clinic  should  be  established,  possibly 
in  the  high-school  building,  but  preferably  as  part  of  the 
main  clinic  for  diagnosis  and  treatment.  A  nose  and 
throat  clinic  should  be  similarly  established,  probably  at 
the  hospital. 

All  of  the  clinic  work  should  be  primarily  on  a  pay  basis, 
as  it  is  essentially  therapeutic  in  character,  special  provision 
being  made  for  necessitous  cases,  after  investigation.  It 
should  be  carried  out  in  close  co-operation  with  the  local 
industries,  local  hospitals,  community  centers,  etc. 

4.  The  Industrial  Group. — Industrial  clinics  should  be 
medical  and  dental  in  character  and  should  be  operated  in 

424 


COMMUNITY  ORGANIZATION 

close  co-operation  with  other  community  agencies.  Work 
should  be  largely  diagnostic,  cases  needing  treatment  being 
referred  to  local  physicians  or  medical  clinics,  except  where 
minor  or  emergency  problems  are  presented.  Single  in- 
dustries employing  from  fifteen  hundred  to  three  thousand 
employees  should  have  independent  clinic  establishments, 
with  at  least  one  full-time  physician  and  two  nurses. 
Smaller  industries,  providing  at  least  first-aid  rooms, 
may  combine  for  part-time  medical  and  nursing  service  or 
may  make  an  arrangement  for  service  with  one  or  another 
of  the  clinics  for  diagnosis  and  treatment.  In  connection 
w4th  the  medical  and  nursing  work  a  certain  amount  of 
outside  work  among  the  families  of  the  employees  may 
cautiously  be  developed,  to  be  carried  out  in  co-operation 
with  school,  district  nursing,  and  other  activities.  All 
of  this  work,  for  the  sake  of  uniformity  and  standardization, 
might  preferably  come  under  at  least  the  advisory  super- 
vision of  the  board  of  health,  if  that  agency  employs  a 
full-time  medical  officer  of  health.  Part  of  the  time  of  this 
official  may  possibly  be  given  to  the  minor  industries  on 
a  part-time  basis. 

5.  Tuberculosis. — In  addition  to  the  medical  and  sanitary 
staff  of  the  local  board  of  health  this  work  w^ill  require  at 
least  the  full  time  of  one  tuberculosis  nurse,  who  will 
divide  her  time  between  the  clinic  and  the  home  work.  The 
clinic  should  be  under  the  direct  supervision  of  the  board  of 
health,  located  centrally,  possibly  with  substations  in  con- 
venient places  in  outlying  neighborhoods  in  the  commimity. 

n.  Clinics  for  Diagnosis  and  Treatment 

Certain  essentials  regarding  these  clinics  may  be  briefly 
indicated  as  follows: 

The  medical  clinics  in  a  community  of  this  size  should  be 
established  under  the  joint  auspices  of  the  local  health  and 
private  hospital  authorities.  They  should  be  located  in 
conjunction  with  the  hospitals,  as  an  out-patient  service, 
and  should  be  made  as  nearly  as  possible  self-supporting. 
They  should  furnish  the  treatment  end  for  the  diagnostic 
work  being  done  in  the  infant  clinics,  in  the  schools,  and  in 

425 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  factories.  Local  medical  talent  should  be  employed 
in  the  routine  work  of  the  clinics,  under  expert  supervision, 
associated  with  a  specialist  consultation  service,  possibly 
developing  gradually  a  certain  amoimt  of  specialization  on 
the  part  of  the  local  physician. 

These  clinics  should  be  operated,  so  far  as  possible,  on  a 
pay,  self-supporting  basis,  with  compensation  for  the  medical 
staff. 

This  medical  clinic  work  is  an  essential  factor  in  any 
complete  community  organization  for  the  prevention  and 
cure  of  disease.  It  is  an  essential  supplement  to  the  infant, 
school,  and  factory  educational  and  diagnostic  work.  It 
is  necessary  in  order  that  all  lines  of  approach  to  the  health 
of  the  community  may  be  made  to  function  to  their  fullest 
advantage.  It  is  a  vital  factor  in  any  attack  upon  the 
community's  death  and  morbidity  rates.  It  must  include 
both  medical  and  surgical  service  and  such  of  the  specialties 
as  can  be  added,  depending  on  local  conditions.  If  there 
are  two  hospitals  in  the  community  which  need  to  be 
considered  from  the  point  of  view  of  co-operation,  the  med- 
ical work  may  perhaps  be  carried  out  by  one,  and  the  surgical 
or  some  of  the  special  work  by  the  other. 

The  functions  of  the  medical  clinic  should  include  the 
making  of  routine  health  examinations  in  co-operation  with 
an  expert  consultation  service,  the  chief  object  being  the 
detection  of  incipient  disease  and  the  establishment  of 
preventive  measures.  Possibly  this  medical  examination 
work  may  be  fostered  by  private  agencies  through  the 
development  of  medical  examination  groups  among  the 
lay  citizens. 

The  clinic  should  provide  a  general  medical  service,  both 
for  minor  ills  and  for  the  more  serious  chronic  affections, 
such  as  the  cardiac,  gastro-intestinal,  and  other  cases. 

If  many  sick  babies  and  children  have  to  be  cared  for,  a 
special  pediatric  division  should  be  provided. 

In  the  surgical  clinic  special  attention  should  be  given 
to  the  minor  surgical  cases.  This  clinic  may  do  industrial 
accident  work  for  small  local  business  enterprises. 

As  to  the  special  clinics,  all  of  these  will  strengthen 

426 


COMMUNITY  ORGANIZATION 

one  another  and  add  greatly  to  the  value  of  the  general 
medical  and  surgical  clinics,  if  all  are  held  in  one  building 
and  under  one  organization.  Ideally,  they  should  be  the 
out-patient  department  of  the  hospital  of  the  town.  WTiere 
this  is  not  possible,  some  of  the  specialties  may  be  in  quarters 
provided  directly  by  the  board  of  health  or  school  board. 

The  eye  clinic  and  the  ear,  nose,  and  throat  clinic  should 
do  both  school  and  adult  work.  An  orthopedic  clinic  is 
very  desirable,  if  a  visiting  orthopedist  can  be  obtained, 
even  if  infrequently.  The  dental  clinic  is  an  essential  ser- 
vice for  children  and  adults  (see  above).  A  venereal  clinic 
should  be  operated  at  least  partly  in  the  evenings  and 
should  be  co-ordinated  with  national  and  state  programs 
to  combat  syphilis  and  gonorrhea. 

m.  The  Cost 

A  very  rough  indication  of  the  probable  gross  cost  of 
such  health-clinic  machinery,  both  to  the  community  and 
to  the  private  agencies,  may  be  indicated  as  follows: 

A.  The  Town  Itself 

1.  A  school  physician  ($2,500),  a  board  of  health 

physician  devoting  part  of  his  time  to  indus- 
trial work  ($3,000),  and  an  infant -welfare 
clinic  physician  ($300) $5,800 

2.  A  part-time  dentist 700 

3.  An  infant-welfare  and  preschool  nurse  ($1,200), 

two  school  nurses  ($2,200),  and  a  tuberculosis 

nurse  ($1,200) 4,600 

4.  Infant  welfare,  school,  and  tuberculosis  clinic 

maintenance 1,500 

Grand  Total $12,600 

B,  Private  Agencies  (Industry) 

1.  Three  industrial  physicians $7,500 

2.  Six  industrial  nurses 7,000 

3.  Industrial  and  general  medical  clinic  mainte- 

nance         3,500 

Grand  Total $18,000 

427 


IMMIGRANT  HEALTH  AND  COMMUNITY 

It  must  be  realized  that  this  cost  will  cover  other  ac- 
tivities not  itemized  in  the  above  list  and  that  very  sub- 
stantial financial  returns  may  be  expected  from  certain  of 
the  services.  Further,  aside  from  financial  returns,  the 
industrial  work  more  than  compensates  the  industries  in 
the  conservation  of  labor,  the  eflficiency  of  employees,  etc. 

The  fact  that  many  essentials  of  this  plan  are 
already  in  operation  in  Framingham,  adds  to  its  value. 

To  put  these  principles  into  practice  all  over  the 
vast  extent  of  the  United  States,  with  its  several 
thousand  small  communities,  is  an  enormous  under- 
taking. The  Framingham  experiment  as  yet  stands 
practically  alone  as  the  one  carefully  considered  effort 
to  deal  with  the  problem,  and  it  is  still  in  its  earlier 
stages.  We  need  at  once  similar  experiments  in  other 
communities  of  different  types.  We  need  constant 
comparison  and  analysis  of  methods  and  results,  so 
as  to  develop  fully  the  principles  on  which  the  methods 
have  been  based,  the  extent  to  which  different  princi- 
ples have  been  successful,  the  reason  for  their  success 
or  their  failure,  and  the  bearing  of  all  this  upon 
national  and  local  programs  of  medical  and  health 
service. 


XIX 

NATIONAL   APPLICATIONS 

The  beginning  of  Americanization  is  with  Americans. 
The  beginning  of  effective  medical  health  work  among 
immigrants  depends  on  the  right  point  of  view  among 
American  health  officers  and  health  workers — a  point 
of  view  which  is  sympathetic,  democratic,  and  based 
on  understanding  of  the  people  with  whom  the  health 
worker  is  dealing. 

Knowledge  of  immigrant  backgrounds  and  charac- 
teristics is  the  right  foundation  for  this  point  of  view, 
and  for  successful  work  with  and  for  the  immigrant. 
Some  knowledge  of  the  language,  even  a  few  words, 
is  most  useful  to  the  field  worker.  But  knowledge  of 
backgrounds  and  characteristics  is  even  more  impor- 
tant because  it  gives  the  ability  to  utilize  interpreters, 
foreign-language  literature,  and  personal  contacts, with 
real  effectiveness. 

TASKS  FOR  NATIONAL  AND  LOCAL  ORGANIZATIONS 

For  the  development  of  technique  with  the  foreign 
born  in  the  various  practical  measures  which  have 
been  outlined,  it  is  desirable  that  there  be  committees 
or  bureaus  of  national  organizations  to  fulfill  the  fol- 
lowing functions : 

(a)  Collation  and  publication  of  the  methods  and 

429 


IMMIGRANT  HEALTH  AND  COMMUNITY 

results  of  local  organizations  in  medical  and  health 
work  with  the  foreign  born.  This  same  body  could 
serve  to  instigate  and  co-ordinate  studies  in  the  vital 
statistics  of  the  foreign  born. 

(b)  Stimulation,  development,  and  standardization 
of  the  education  of  field  workers  for  effective  service 
among  the  foreign  born. 

(c)  Practical  assistance  to  local  organizations  in  the 
development  of  medical  and  health  service  for  their 
immigrant  population.  This  will  be  particularly  valu- 
able du,ring  the  next  few  years,  when  all  experiments 
along  this  line  will  be  profitable  to  other  communities. 

There  is  a  tendency  in  America  for  every  new  idea 
to  call  forth  a  new  organization.  The  development  of 
better  medical  and  health  work  for  the  foreign  born 
in  this  country  is  not  a  new  idea,  but,  as  this  survey 
has  shown,  special  attention  to  the  foreign  born  is  not 
yet  characteristic  of  American  medical  and  health 
agencies.  Much  must  be  done  to  put  into  practice  by 
the  many  the  ideas,  the  ideals,  and  the  methods  which 
have  already  been  conceived  or  tested  out  by  the  few. 
Yet  this  advance  ought  not  to  require  a  new  organiza- 
tion. There  are  already  in  existence  a  host  of  national 
societies,  local  associations,  and  governmental  agen- 
cies performing  medical  or  health  work,  training  medi- 
cal or  health  workers,  carrying  on  research,  or  devoting 
themselves  to  publicity  and  popular  health  education. 

The  chief  organizations  carrying  on  curative  medical 

work  are  the  hospitals  and  the  dispensaries.    Some  of 

these  are  organized  locally,  and  the  whole  body  have 

their  national  organization,  the  American  Hospital 

Association.     The  visiting  nurses  and  the  medical 

social  workers  of  the  country  are  each  nationally 

430 


NATIONAL  APPLICATIONS 

organized.  So  are  the  dietitians.  In  the  field  of  pre- 
ventive medicine  the  health  departments  and  the 
militant  health  agencies  have  several  national  and 
many  state  organizations.  Chief  among  these  is  the 
American  Public  Health  Association.  The  aim  is  to 
make  each  of  these  organizations  perceive  that  the 
successful  accomplishment  of  its  purpose  requires  more 
attention  to  the  special  problems  of  the  foreign  born 
and  to  the  special  methods  necessary  for  greatest 
efficiency  in  work  among  them. 

Considering  the  already  bewildering  multiplicity  of 
medical  and  health  organizations  in  the  United  States, 
it  is  unwise  to  establish  a  new  organization  if  it  can 
be  avoided.  The  study  of  the  problems  of  health  and 
disease  among  the  foreign  born,  and  of  better  methods 
for  their  solution,  ought  rather  to  be  undertaken  by 
special  sections  or  committees,  or  specially  appointed 
executives,  of  existing  organizations. 

National  and  state  organizations  do  not,  as  a  rule, 
undertake  much  detail  work  in  the  field,  but  confine 
their  efforts  to  research,  publicity,  or  advisory  service. 
Such  bodies  sometimes  subsidize  local  organizations 
for  a  piece  of  research  or  of  experimental  field  work. 
Further  comparison  of  the  morbidity  and  mortality 
statistics  for  native  and  foreign  born,  and  for  different 
race  groups,  is  one  of  the  fundamental  and  constructive 
tasks  ahead.  All  local,  state,  and  national  organiza- 
tions having  anything  to  do  with  medical  or  health 
work,  have  a  direct  interest  in  such  investigations. 
Among  the  organizations  which  have  already  collected 
statistics  on  this  subject,  or  have  pursued  special  in- 
vestigations, are  the  United  States  Census  Bureau, 

life-insurance  companies,  local  and  state  departments 

431 


IMMIGRANT  HEALTH  AND  COMMUNITY 

of  health,  and  local  voluntary  medical  and  health 
agencies.  Sporadic  investigations  of  this  type  need 
both  encouragement  and  co-ordination. 


NEED  FOR  A  CENTRAL  STANDARDIZING  AGENCY 

It  would  be  well  for  some  national  body,  representative 
of  these  various  organizations,  to  serve  as  a  central 
stimulative  and  advisory  agent — helping  to  standard- 
ize technique  so  that  the  results  of  different  studies 
should  be  comparable,  suggesting  new  problems  or 
questions  on  which  research  is  needed,  and  collating, 
publishing,  or  stimulating  the  publication  of  co- 
ordinated results  and  surveys. 

A  Committee  or  Bureau  on  Health  Work  with  the 
Foreign  Born,  of  a  representative  national  body  prop- 
erly financed,  would  fulfill  a  highly  important  national 
function,  not  only  in  stimulating  statistical  research, 
but  also  in  collating  and  advancing  methods  of  health 
education  and  field  work  among  the  foreign  born,  and 
in  disseminating  whatever  knowledge  and  advice  such 
activities  would  yield. 

TRAINING  HEALTH  WORKERS 

The  training  of  health  workers  for  successful  service 
among  the  foreign  born  is  another  major  task.  Among 
the  organizations  now  chiefly  concerned  with  such 
training  are  the  schools  for  health  officers,  the  nurses' 
training  schools,  particularly  those  schools  offering 
special  courses  in  public-health  nursing,  and  the  spe- 
cial schools  or  college  departments  which  are  training 
men  and  women  for  social  service.    The  most  numer- 

432 


NATIONAL  APPLICATIONS 

ous  body  of  workers  actually  engaged  in  the  applica- 
tion of  medical  and  health  service  to  the  foreign  born 
are,  and  will  remain  for  an  indefinite  period,  the  visit- 
ing nurses. 

The  development  of  better  educational  methods, 
and  the  study  and  advancement  of  better  technique 
in  field  work  among  the  foreign  born,  would  seem  a 
subject  particularly  appropriate  for  the  National  Or- 
ganization for  Public  Health  Nursing.  The  several 
thousand  local  visiting-nursing  associations  through- 
out the  country,  large  and  small,  are  experiment  sta- 
tions in  methods  of  field  work,  and  include  a  consid- 
erable number  of  centers  in  which  public-health  nurses 
are  trained.  In  this,  as  in  other  phases  of  health 
work,  experience  with  the  foreign  born  is  accumulating. 

In  order,  however,  to  make  this  phase  of  experience 
valuable,  it  must  be  continuously  watched  and  peri- 
odically surveyed  and  collated.  A  special  secretariat  on 
work  with  the  foreign  born,  if  connected  with  a  body 
like  the  National  Organization  for  Public  Health 
Nursing,  would  be  a  highly  important  contribution 
to  the  technique  of  medical  and  health  work  through- 
out the  United  States  and  to  the  education  of  new 
workers. 

A  CLEARING  HOUSE  FOR  INFORMATION  AND  METHODS 

It  is  much  to  be  hoped  that  various  special  problems 
touched  upon  in  the  course  of  this  volume  may  be 
taken  up  by  appropriate  national  bodies.  For  exam- 
ple, hospital  and  institutional  dietaries  must  be 
adapted  to  the  needs  of  immigrant  patients ;  dietitians, 

nurses,  and  social  workers  can  also  help  to  adapt 

433 


IMMIGRANT  HEALTH  AND  COMMUNITY 

budgets  to  needs  and  tastes  in  immigrant  families. 
Departments  of  dietetics  or  home  economics  in  col- 
leges and  universities  ought  to  devote  more  attention 
to  this  subject,  and  the  American  Dietetic  Association, 
through  its  conventions  and  its  committee  work, 
should  pursue  it  systematically. 

The  important  service  which  the  American  Medical 
Association  has  rendered  in  enlightening  the  medical 
profession  and  the  public  about  the  quack,  has  been 
limited  thus  far  to  the  relations  of  the  quack  and  of 
undesirable  proprietary  medicines  to  the  English- 
speaking  population.  It  is  to  be  hoped  that  this 
association  will  devote  attention  to  the  situation  in 
the  foreign-language  field  and  to  the  conditions  of 
quack  practice  among  the  foreign  born. 

The  more  discriminating  and  effective  use  of  health 
literature  especially  prepared  for  the  foreign  born,  the 
preparation  of  exhibits  and  other  educational  measures 
for  them,  falls  necessarily  within  the  field  work  of 
local  militant  health  agencies.  But  a  great  economy 
and  a  gain  in  efficiency  would  be  brought  about  if 
national  bodies  gave  the  expert  service  which  is  rarely 
available  to  local  organizations.  The  life-insurance 
companies  could  render  notable  service  in  this  field 
to  many  health  organizations  as  well  as  to  some  of 
their  own  industrial  policy  holders.  Such  a  committee 
of  a  representative  national  body  as  has  already  been 
suggested,  could  serve  as  a  bureau  for  the  collection 
and  collation  of  methods,  the  expert  preparation  and 
translation  of  literature  and  posters,  rendering  the 
best  accessible  to  all,  and  stimulating  the  develop- 
ment of  still  better. 

Such  an  organization  as  the  American  Hospital  As- 

434 


NATIONAL  APPLICATIONS 

sociation,  or  perhaps  the  newly  formed  American 
Conference  on  Hospital  Service,  would  seem  naturally 
to  have  for  its  field  the  humanization  and  improve- 
ment of  methods  for  adapting  hospital  and  dispensary 
service  to  the  needs  of  immigrant  patients.  Any  one 
of  the  specialized  militant  health  agencies,  such  as  the 
National  Tuberculosis  Association  or  the  American 
Social  Hygiene  Association,  could  take  up  special 
investigation,  advisory  or  experimental  field  work,  to 
improve  its  policies  and  methods  among  the  foreign 
born.  The  United  States  Public  Health  Service  and 
governmental  agencies  in  the  states  might  take  an 
advanced  position  in  this  matter  through  a  special 
bureau  or  detail  of  officers.  But  most  of  the  activities 
required  in  the  immediate  future  demand  a  freedom 
and  camaraderie  which  call  for  the  private  voluntary 
organization. 

STIMULATION   OF   LOCAL   ORGANIZATION 

There  remains  a  third  need  which  no  one  of  these 
organizations  can  fulfill — namely,  to  encourage  and 
assist  local  organizations  to  devote  themselves  more 
effectively  to  medical  and  health  work  among  the 
foreign  born.  The  postwar  program  of  the  American 
Red  Cross  is  largely  a  health  movement.  In  the  fore- 
ground, as  thus  far  announced,  stands  the  stimulation 
of  health  centers  throughout  the  United  States.  This 
activity  of  the  Red  Cross,  according  to  the  preliminary 
utterances  of  its  officers,  has  particular  application  to 
smaller  communities,  and  is  to  be  democratically  con- 
ducted by  a  stimulative  and  advisory,  instead  of  a 

centralized  method  of  government. 

435 


IMMIGRANT  HEALTH  AND  COMMUNITY 

As  has  already  been  pointed  out,  a  large  part  of  the 
health  center  work  thus  far  undertaken  has  been  in 
districts  or  communities  largely  populated  by  the 
foreign  born;  in  fact,  such  a  situation  is  inevitable,  if 
health  centers  are  to  be  established  in  sections  of  cities 
or  in  smaller  communities  where  the  need  is  greatest. 
The  health  center  will  be  a  name  covering  many  dif- 
ferent types  of  work,  sometimes  ranging  outside  of  the 
medical  and  health  field,  but  medical  and  health  work 
will  always  be  included  in  the  activities  of  such  centers. 
In  any  case,  successful  results  will  in  a  large  propor- 
tion of  localities  depend  upon  the  ability  of  those  con- 
ducting the  work  to  deal  with  the  problems  and  per- 
sonalities of  foreign-born  Americans. 

The  health-center  program  of  the  Red  Cross  will 
be  of  increased  assistance  to  the  local  organizations  of 
the  Red  Cross  and  to  other  local  bodies  which  will 
actually  conduct  the  health  centers,  if  the  national  or 
division  organization  of  the  Red  Cross  gives  special 
advice  and  aid  in  the  health  problems  of  the  foreign 
born  and  the  best  ways  of  meeting  them.  Such  as- 
sistance should  be  rendered  largely  through  an  expert 
advisory  staff,  which  will  be  subject  to  the  call  of  local 
chapters  or  any  appropriate  local  organization — a 
staff  familiar  with  the  backgrounds  and  characteris- 
tics of  different  immigrant  groups,  with  their  problems 
and  the  policies  and  methods  of  dealing  with  them. 

It  might  be  desirable  in  some  instances  if  the  Red 
Cross  financed  organizations  selected  to  work  out 
certain  typical  medical  and  health  problems  with  the 
foreign  born,  particularly  if  the  results  and  methods 
which  achieved  them  could  be  recorded,  written  up, 
and  published  so  as  to  be  accessible  for  all. 

436 


NATIONAL  APPLICATIONS 

If  such  national  organizations  as  the  American 
Pubhc  Health  Association,  the  National  Organization 
for  Public  Health  Nursing,  and  the  American  Red 
Cross,  will  take  part  in  the  advancement  of  our  knowl- 
edge concerning  the  health  problems  of  the  foreign 
born  and  in  the  practical  development  and  application 
of  better  methods  for  solving  these  problems,  we  may- 
hope  for  rapid  and  continuous  advancement  in  the 
application  of  existing  scientific  knowledge  to  secure 
far-reaching  human  results. 

HEALTH   WORK  AND   NATIONAL  STAMINA 

Is  medical  and  health  work  a  desirable  agent  of 
natural  selection?  By  the  refinement  of  methods  for 
the  detection  and  cure  of  disease,  by  the  promotion  of 
measures  which  sustain  health  and  prolong  life,  do 
we  bolster  up  the  weak,  aid  them  to  propagate  their 
kind,  and  lower  the  future  physiological  stamina  of 
our  people?  Has  the  improvement  of  methods  of 
medical  and  health  work  among  the  foreign  born  in 
this  country  anything  to  do  with  such  an  undesirable 
natural  selection,  if  it  exists? 

Behind  these  questions  lie  the  fears  and  prejudices 
of  many.  Let  us  try  to  approach  them  without  either 
prejudice  or  fear. 

The  influence  of  immigration  on  the  physical  char- 
acteristics of  the  people  of  the  United  States  is  a 
subject  upon  which  no  adequate  body  of  definite  in- 
formation exists.  Decennial  censuses  give  us  cross 
sections  and  race  constitution  after  a  fashion,  but  they 
tell  us  little,  and  as  the  children  of  immigrants  grow 
up,  marry,  and  have  children,  these  members  of  the 
third  generation  are  native  born,  of  native  parents, 

29  437 


IMMIGRANT  HEALTH  AND  COMMUNITY 

and  pass  out  of  the  census  tables,  so  far  as  any  racial 
analysis  is  concerned. 

For  instance,  we  have  almost  no  information  on 
such  a  fundamental  question  as — ^how  rapidly  is  amal- 
gamation by  marriage  proceeding  between  native  born 
and  foreign  born?  What  race  groups  tend  most 
rapidly  to  amalgamate  thus?  What  are  the  effects  of 
such  unions  upon  the  physical,  mental,  and  moral 
characteristics  of  the  children?  Opinions  can  be  found 
without  number  on  this  subject  of  amalgamation,  born 
of  race  pride  or  race  prejudice,  or  of  religious  or  local 
divisions.  These  take  us  nowhere.  We  must  have 
facts  if  we  are  to  reach  conclusions. 

NO  INHERENT  RACIAL  SUPERIORITY 

In  the  absence  of  facts  the  only  conclusions  which  we 
should  reach  is  that  well  expressed  by  Prof.  Franz 
Boas  in  his  notable  book  The  Mind  of  Primitive  Man. 
He  holds  up  to  daylight  the  prevalent  assumption  of  ^ 

.  .  ,  the  existence  of  gifted  races  and  of  others  less 
favorably  endowed,  and  (we  have)  found  that  it  was 
based  essentially  on  the  assumption  that  higher  achieve- 
ment is  necessarily  associated  with  higher  mental  faculty, 
and  therefore  the  features  of  those  races  that  in  our  judg- 
ment have  accomplished  most  are  characteristics  of  mental 
superiority.  We  subjected  these  assumptions  to  a  critical 
study  and  discovered  little  evidence  to  support  them. 
So  many  other  causes  were  found  to  influence  the  progress 
of  civilization,  accelerating  or  retarding  it,  and  similar 
processes  were  active  in  so  many  different  races  that,  on 
the  whole,  hereditary  traits,  more  particularly  hereditary 
higher  gifts,  were  at  best  a  possible,  but  not  a  necessary, 
element  determining  the  degree  of  advancement  of  a  race. 

I  hope  the  discussions  contained  in  these  pages  have 

*  Franz  Boas,  The  Mind  of  Primitive  Man,  pp.  244-278. 

433 


NATIONAL  APPLICATIONS 

shown  that  the  data  of  anthropology  teach  us  a  greater 
tolerance  of  forms  of  civilization  dififerent  from  our  own, 
and  that  we  should  learn  to  look  upon  foreign  races  with 
greater  sympathy,  and  with  the  conviction  that,  as  all 
races  have  contributed  in  the  past  to  cultural  progress  in 
one  way  or  another,  so  they  will  be  capable  of  advancing 
the  interests  of  mankind,  if  we  are  only  willing  to  give  them 
a  fair  opportunity. 

RELATIVE    BIRTH    RATE    UXMPORTAXT 

Some  facts  exist  on  the  relative  rate  of  propagation 
of  diflFerent  race  groups  in  the  L'nited  States.  We  are 
periodically  shaken  and  shocked  by  reports  that  the 
American  native  stock  is  dying  out,  that  the  Poles  or 
the  Jews  or  the  Italians  or  other  races  of  immigrants 
are  having  so  many  children  per  mother  that  they, 
and  not  the  Anglo-Saxons,  shall  inherit  this  fair  Ameri- 
can earth. 

A  few  such  statistics  have  been  quoted  indicating 
the  apparently  high  fecundity  of  foreign-born  women. 
But  it  was  pointed  out  that  unless  the  age  classifica- 
tion of  native  and  foreign  women  of  different  races  is 
standardized,  we  are  likely  to  be  led  into  error.  If  a 
group  of  foreign-born  married  women  happen  to  aver- 
age even  a  few  years  younger  than  do  the  American- 
bom  married  women  of  the  same  community  or  other 
area,  the  number  of  children  per  mother  would  be 
certainly  greater  among  the  foreign-born  women  than 
the  native.  Yet  this  difference  would  be  due  to  the 
fact  that  the  foreign-born  women  had  chiefly  come  to 
this  country  during  the  early  years  of  the  childbearing 
period,  and  did  not  represent  as  large  a  number  of 
women  at  the  older  childbearing  ages  as  a  normal 

population  does. 

439 


IMMIGRANT  HEALTH  AND  COMMUNITY 

The  difference  between  a  greater  physiological  fer- 
tility of  the  foreign-born  women  and  the  actual  num- 
ber of  children  per  mother  is  a  difference  of  great 
importance,  and  would  appear  in  the  next  generation. 
On  this  subject  we  have  as  yet  practically  no  informa- 
tion. Meanwhile  let  us  not  hasten  to  conclusions  as 
to  what  race  will  inherit  the  American  earth. 

The  differences  in  death  rate  are  no  less  significant 
than  those  of  birth  rate.  We  have  seen  that  the  death 
rate  of  the  foreign  born,  in  spite  of  more  favorable 
age  distribution,  is  on  the  average  distinctly  higher 
than  that  of  the  natives.  We  have  seen  that  the  in- 
fant death  rate  of  several  foreign-born  groups  con- 
cerning whom  the  fears  and  prejudices  of  some  native 
Americans  have  been  especially  roused  is  particularly 
high;  sometimes  double,  sometimes  treble  or  more 
than  treble  that  of  the  native  born  in  the  same  com- 
munity. We  need  much  further  study  to  determine 
how  far  the  higher  infant  death  rate  among  the  foreign- 
born  groups  is  equating  their  higher  birth  rate  to  the 
net  birth  rate  of  the  native  born.  Since  the  foreign  born 
are  apparently  subject  to  a  higher  death  rate  during 
childhood  and  also  through  adult  life,  the  same  study 
would  have  to  be  pursued  to  later  age  periods  than  in- 
fancy in  order  to  reach  a  conclusion  as  to  the  net  result. 

The  descendant  of  the  Mayflower  reads,  perhaps, 

with  a  mingling  of  awe  and  pride  of  the  families  of 

twelve  to  twenty-four  children,  so  prevalent  in  the 

days  of  Cotton  Mather.     Those  families,  he  learns, 

often  succeeded  in  killing  several  mothers  before  they 

were  completed.    Such  large  families  were  the  natural 

reaction  of  a  vigorous  people  to  a  new  country  in 

which  children  were  an  asset,  and  in  which  conditions 

440 


NATIONAL  APPLICATIONS 

of  life  were  more  favorable  in  many  respects  than 
those  which  they  had  left  abroad.  The  native  Indians 
of  New  England  at  the  time  of  Cotton  Mather,  the 
real  Americans  of  that  day,  apparently  had  small 
families.  The  descendant  of  the  Mayflower  now  sees 
history  repeating  itself.  The  immigrants,  recently 
come  to  a  more  favored  country  than  their  native 
land,  are  having  larger  families  than  those  who  have 
been  here  longer  and  who  have  accepted  certain 
standards  w^hich  tend  to  reduce  the  number  of  chil- 
dren in  a  family. 

There  is  not  a  little  evidence  that  some  sections  of 
the  native  white  American  stock  are  having  not  only 
much  smaller  families  than  the  foreign  stock,  but 
families  so  small  that  the  stock  will  not  keep  up  its 
numbers  in  the  next  generation.  But  we  have  no 
physiological  or  sociological  evidence  to  prove  that 
this  in  itself  is  an  evil,  even  if  it  be  generally  true 
among  the  native  born,  or  that  the  relatively  greater 
fertility  of  recent  immigrants  is  an  evil  or  is  likely  to 
be  permanent,  whether  it  is  evil  or  good. 

We  may  be  fairly  sure  of  one  point — that  the  psycho- 
logical process  of  Americanization  proceeds  so  much 
more  rapidly,  at  least  after  the  first  generation,  than 
any  biological  process  of  natural  selection  can  possibly 
proceed,  that  whatever  changes  take  place  in  the 
characteristics  of  our  population  within  a  period  of 
fifty  to  a  hundred  years  will  be  determined  much 
more  by  psychological  and  sociological  than  by  bio- 
logical factors.  The  rate  of  social  and  spiritual  fusion 
of  native-born  and  foreign-born  elements  in  America 
is  probably  the  ultimate  determinant  of  the  more 
important  conditions  affecting  the  rates  of  net  in- 

441 


IMMIGRANT  HEALTH  AND  COMMUNITY 

crease  for  races  of  different  origins.  In  so  far  as  eco- 
nomic status  and  standards  of  living  influence  birth 
and  death  rates,  the  governing  influences  are  psycho- 
logical and  social. 

Again  we  lack  facts  concerning  the  effects  of  amal- 
gamation. Dr.  Charles  B.  Davenport  has  pointed  out 
some  of  the  possible  physical  consequences  of  amal- 
gamating different  races.^ 

If  one  parent  belong  to  a  tall  race — like  the  Scotch  or 
some  of  the  Irish — and  the  other  to  a  short  race,  like  the 
South  Itahans,  then  all  the  progeny  will  tend  to  be  inter- 
mediate in  stature.  If  two  such  intermediates  intermarry, 
then  very  short,  short,  medium,  tall,  and  very  tall  offspring 
may  result  in  proportions  that  cannot  be  precisely  given, 
but  about  which  one  can  say  that  the  mediums  are  the 
commonest  and  the  more  extreme  classes  are  less  frequent, 
the  more  they  depart  from  mediocrity.  In  this  case  of 
stature  we  do  not  have  to  do  with  merely  one  factor  as  in 
eye  color,  or  two  as  in  negro  skin  color,  but  probably  many. 
That  is  why  all  statures  seem  to  form  a  continuous  curve 
of  frequency  with  only  one  modal  point,  that  of  the  median 
class. 

But  I  am  aware  that  I  have  not  yet  considered  the  main 
problem  of  the  consequence  of  race  intermixture,  consider- 
ing races  as  differing  by  a  number  of  characters.  First, 
I  have  to  say  that  this  subject  has  not  been  sufficiently  in- 
vestigated; but  we  may,  by  inference  from  studies  that 
have  been  made,  draw  certain  conclusions.  Any  well- 
established  abundant  race  is  probably  well  adjusted  to  its 
conditions  and  its  parts  and  functions  are  harmoniously 
adjusted.  Take  the  case  of  the  Leghorn  hen.  Its  func- 
tion is  to  lay  eggs  all  the  year  through  and  never  to  waste 
time  in  becoming  broody.  The  brooding  instinct  is,  indeed, 
absent;  and  for  egg  farms  and  those  in  which  incubators 
are  used  such  birds  are  the  best  type.  The  Brahma  fowl, 
on  the  other  hand,  is  only  a  fair  layer;  it  becomes  broody 

^  C.  B.  Davenport,  The  Effects  of  Race  Intermingling,  pp.  365-366. 

442 


NATIONAL  APPLICATIONS 

two  or  three  times  a  year  and  makes  an  excellent  mother. 
It  is  well  adapted  for  farms  which  have  no  mcubators  or 
artificial  brooders.  Now  I  have  crossed  these  two  races; 
the  progeny  were  intermediate  in  size.  The  hens  laid 
fairly  well  for  a  time  and  then  became  broody  and  m 
time  hatched  some  chicks.  For  a  day  or  two  they  mothered 
the  chicks,  and  then  began  to  roost  at  night  in  the  trees 
and  in  a  few  days  began  to  lay  again,  while  the  chicks 
perished  at  night  of  cold  and  neglect.  The  hybrid  was  a 
failure  both  as  egg  layer  and  as  a  brooder  of  chicks.  The 
mstincts  and  functions  of  the  hybrids  were  not  harmoniously 
adjusted  to  each  other. 

Turning  to  man,  we  have  races  of  large,  tall  men,  like 
the  Scotch,  which  are  long  lived  and  whose  internal  organs 
are  weU  adapted  to  care  for  the  large  frames.  In  the 
south  Italians,  on  the  other  hand,  we  have  small,  short 
bodies,  but  these,  too,  have  well-adjusted  viscera.  But 
the  hybrids  of  these  or  similar  two  races  may  be  expected 
to  yield,  in  the  second  generation,  besides  the  parental 
t5T)es,  also  children  with  large  frame  and  madequate  viscera 
—children  of  whom  it  is  said  every  inch  over  5'  10"  is  an 
mch  of  danger,  children  of  msufficient  circulation.  On  the 
other  hand,  there  may  appear  children  of  short  stature 
with  too  large  cu-culatory  apparatus.  Despite  the  great 
capacity  that  the  body  has  for  self-adjustment,  it  faHs 
to  overcome  the  bad  hereditary  combinations. 

Again  it  seems  probable,  as  dentists  with  whom  I  have 
spoken  on  the  subject  agree,  that  many  cases  of  over- 
crowding or  wide  separation  of  teeth  are  due  to  a  lack  of 
harmony  between  size  of  jaw  and  size  of  teeth— probably 
due  £o  a  union  of  a  large-jawed,  large-toothed  race  and 
a  small-jawed,  small-toothed  race.  Nothing  is  more  strik- 
ing than  the  regular  dental  arcades  commonly  seen  m  the 
skuUs  of  mbred  native  races  and  the  irregular  dentations 
of  many  children  of  the  tremendously  hybridized  Americans. 

MODERN   FITNESS   DEFINED 

From  these  excursions  into  the  desert  of  surmise  we 
may  return  to  our  original  question  as  to  the  effects 

443 


IMMIGRANT  HEALTH  AND  COMMUNITY 

of  medical  and  health  work  upon  different  race 
groups  within  the  United  States,  and  the  resulting 
net  quality  of  our  population.  Does  the  improvement 
of  methods  of  medical  care  tend  toward  keeping  alive 
the  unfit?  Does  the  wider  application  of  better 
methods  of  medical  care  to  larger  groups  of  the  popu- 
lation tend  to  keep  alive  many  of  the  weak  and  un- 
developed, who  can  be  little  more  than  a  burden 
upon  themselves  and  the  community?  Does  success 
in  the  prevention  of  disease  tend  in  the  same  direction? 
"Fitness"  is  a  relative  term.  Fitness  for  modern 
life  is  not  the  same  as  for  the  life  of  the  cave  man,  the 
mediaeval  knight,  or  his  manorial  peasant.  The  hap- 
piest and  most  efficient  living  demands  a  sound  body. 
But  success  in  modern  life  and  fitness  for  success  in  it 
depend  primarily  upon  a  good  sound  mind.  Many 
of  the  chief  epidemic  diseases  to  which  the  civilized 
portions  of  the  human  race  are  now  subject  appear  to 
exercise  very  little  selection  of  the  physically  weak 
over  the  physically  strong.  Some  diseases  appear  to 
strike  the  strong  rather  than  the  weak.  One  out- 
standing and  important  truth  has  come  forth  as  the 
result  of  modern  preventive  medicine — namely,  that 
under  conditions  of  modern  civilized  life  the  mainte- 
nance of  bodily  health  depends  on  intelligence  and 
self-control  more  than  on  anything  else. 

NATURAL   SELECTION   PROMOTED 

Successful  results  in  the  cure  of  disease  when  it  has 
come  upon  individuals  depend  to  a  considerable  de- 
gree upon  the  intelligence  and  co-operation  of  the 
patient,  or  of  the  patient's  parents  if  the  sick  person 

be  a  child.     Success  in  preventing  disease  depends 

444, 


NATIONAL  APPLICATIONS 

almost  entirely  upon  the  intelligence  and  the  power  of 
self-control  of  the  individual  and  the  group  in  which 
he  lives.  The  tendency  of  properly  directed  efforts 
toward  the  cure  and  the  prevention  of  disease  is 
toward  the  preservation  of  those  elements  of  our 
population  which  are  capable  of  intelligent  response, 
and  of  physical  and  moral  self-control. 

Stupid  mothers  may  have  babies,  but  mothers  who 
will  not  learn  how  to  take  care  of  their  babies  will 
lose  them.  Syphilis  and  gonorrhea  are  probably  the 
greatest  single  causes  of  the  failure  of  individuals 
to  reproduce  their  kind.  The  ultimate  success  of 
prophylaxis  of  syphilis  and  gonorrhea  rests  upon  the 
ability  of  individuals  to  understand  what  these  dis- 
eases are  and  to  live  such  lives  as  will  avoid  incurring 
them.  Those  who  cannot  learn,  or  who  have  not  the 
stuff  in  them  to  practice  what  they  learn,  will  suffer. 
Others,  indeed,  may  suffer  innocently,  but  in  the  main 
the  proposition  stands.  The  curative  measures  which 
stand  in  the  forefront  of  the  practical  campaign  against 
syphilis  and  gonorrhea  depend  for  their  success  largely 
upon  the  intelligent  co-operation  of  the  patients;  and 
perhaps  the  most  far-reaching  value  of  these  curative 
resources,  such  as  clinics,  is  the  opportunity  they  give 
for  effective  education  of  individuals  and  families  in 
the  nature,  the  dangers,  and  the  prevention  of  venereal 
diseases. 

Better  medical  and  health  work  among  the  foreign 
born  is  not,  according  to  these  principles,  a  measure 
which  promotes  the  survival  of  the  unfit,  but  a  means 
of  prolonging  the  life  and  promoting  the  efficiency  of 
those  who  have  the  intelligence  and  capability  to  re- 
spond to  the  opportunities  offered.     Well-conceived 

445 


IMMIGRANT  HEALTH  AND  COMMUNITY 

measures  to  provide  medical  facilities  for  the  care  of 
disease,  and  educational  and  other  measures  for  its 
prevention,  tend  to  select  population  on  the  basis  of 
intellectual  and  moral  quality  more  than  they  tend 
to  perpetuate  the  weak  and  the  unfit. 

THE  DEMOCRATIC  PROCESS 

This  is  true  at  least  when  there  is  no  barrier  of  con- 
viction or  prejudice  between  those  who  are  offering 
curative  and  preventive  services  and  those  to  whom 
they  are  offered.  If  American  methods  of  medical 
and  health  work  are  such  as  to  provoke  and  maintain 
prejudice  and  opposition  among  the  foreign  born,  then 
the  value  of  our  preventive  measures  particularly  is 
reduced  to  a  minimum,  and  our  curative  facilities 
attract  only  the  weak  and  incapable  members  of  their 
group — who  do  not  share  their  group  spirit  enough 
to  stand  with  their  own  people. 

The  great  danger  to  medical  and  health  work  with 
the  foreign  born  is  that  wrong  relations  may  be  estab- 
lished between  the  native  Americans  and  the  immi- 
grants; that  the  native  Americans  may  proceed  with 
a  theory  of  offering  charity,  or  with  a  set  of  prejudices 
in  the  back  of  their  minds,  or  with  a  smile  of  contempt, 
even  when  they  are  offering  help.  The  only  possible 
reaction  of  any  self-respecting  foreign  group  to  such 
policies  and  methods  is  to  meet  prejudice  and  an- 
tagonism with  prejudice  and  contempt.  In  these 
circumstances,  even  when  actual  services  are  accepted 
in  time  of  bitter  need,  mutual  understanding  and  co- 
operation will  not  develop. 

Measures  for  medical  and  health  work  among  the 

446 


NATIONAL  APPLICATIONS 

foreign  born,  conceived  and  carried  out  in  a  co- 
operative and  democratic  spirit,  adapting  American 
policies  and  points  of  view  to  immigrant  backgrounds 
and  characteristics,  are  helpful  agents  in  the  selection 
of  the  most  desirable  elements  of  each  race  group  as 
participants  in  American  life.  The  duty  of  America 
is  to  regard  the  promotion  of  health  as  at  least  as 
fundamental  as  the  promotion  of  education.  America 
ought  to  provide  facilities  for  the  care  of  illness  and 
for  the  prevention  of  disease  according  to  the  best 
standards  known  to  science,  and  to  render  these 
facilities  accessible  to  all  on  terms  they  will  under- 
stand, so  that  they  will  use  them  when  they  need 
them. 

Co-operation  between  those  who  render  the  service 
and  those  who  receive  it  is  the  only  policy  compatible 
with  democracy.  Health  is  one  of  the  inclusive  and 
continuing  interests  of  life,  beginning  when  the  mother 
first  feels  the  stir  of  the  coming  child,  and  ending  only 
with  the  last  breath.  Americanization  is  the  effort  of 
a  great  multitudinous  population  toward  the  creation 
of  a  united,  harmonious,  self-determining  people.  Co- 
operation of  all  elements  of  our  population  in  a  com- 
mon effort  toward  happier  and  more  efficient  living 
must  include  mutual  endeavors  toward  realizing  the 
best  in  physical  well-being,  as  well  as  the  best  in  eco- 
nomic conditions,  political  organization,  and  cultural 
activities. 

Such  an  effort  requires  participation  by  all  race 

groups  in  the  acquirement  of  the  knowledge  that 

science  gives  of  the  laws  of  life,  the  nature  of  disease, 

and  the  practical  arts  of  hygiene.     Organization  to 

promote  such  co-operative  effort  for  health  is  part  of 

447 


IMMIGRANT  HEALTH  AND  COMMUNITY 

the  task  of  any  community,  and  will  create  a  truly 
American  democracy  and  not  a  stratified  or  segre- 
gated community  of  different  races.  The  inclusion  of 
medical  and  health  work  in  the  program  of  Ameri- 
canization is  not  only  the  task  of  the  physician  and 
the  professional  administrator,  but  of  the  teacher  and 
the  statesman. 


APPENDIX 

RECIPES  OF  THE  FOREIGN  BORN 

The  Italians 

The  following  are  prescribed  for  undernourished  children: 
1.  Zuppa  alia  Provinciale  (Potato  Soup) 

2  large  potatoes  2  tablespoonfuls  butter 

3  tablespoonfuls  milk  2  egg  yolks 

4  cupfuls  soup  stock 

Boil  potatoes;  rub  through  sieve.  Put  in  saucepan  with 
butter,  salt,  and  milk.  Simmer  until  thick,  then  add  egg 
yolks  to  form  it  into  a  paste.  Turn  on  to  bread  board, 
cut  into  small  dice,  and  throw  into  the  soup  stock,  which 
must  be  boiling. 

2.  Zuppa  di  Lattuga  (Lettuce  Soup) 

1  head  lettuce  2  tablespoonfuls  green  peas 

2  potatoes  1  heaping   tablespoonful 

1  head  of  celery  ^our 

4  cupfuls  soup  stock 

Cook  all  together  for  one  hour  and  a  half  and  serve  with 
toasted  squares  of  bread. 

3.  Zuppa  di  Zucca  (Pumpkin  Soup) 

3  pounds  sliced  pumpkin        i  cupful  water 

2  tablespoonfuls  butter  If  cupfuls  milk 

1  tablespoonful  sugar 

Peel  pumpkm,  cut  into  pieces,  cook  in  water  with  butter, 
sugar,  and  salt  for  two  hours.  Drain  and  add  to  milk 
which  has  been  heated.     Bring  to  a  boil  before  servmg. 

449 


IMMIGRANT  HEALTH  AND  COMMUNITY 

4.  Brodo  di  Lenticchie  (Lentil  Soup) 
3  tablespoonfuls  dried  len-      2  tablespoonfuls  milk 
tils  4  cupfuls  soup  stock 

5  tablespoonful  butter 

Cover  lentils  with  water  and  simmer  until  soft;  put 
through  sieve.  Melt  butter  in  saucepan,  add  lentils  and 
milk;  mix  well.  Add  a  cupful  of  stock,  and  this  to  three 
cupfuls  of  hot  stock. 

Some  of  the  Italian  soups  more  nearly  resembling  our  own 
are  minestrone  alia  Milanese  or  vegetable  chowder,  brodo  di 
capone,  or  chicken  soup,  and  brodo  di  carne^  or  vegetable  and 
beef  soup.    Milk  soups  are  rarely  used  by  the  Italians. 

Milk  may  be  given  plain  or  in  custards,  as  in  gnocchi 
of  milk  or  in  zabione. 

5.  Gnocchi  of  Milk 
1  cupful  milk  3  drops  vanilla 

1  level  tablespoonful  corn-      2  egg  yolks 

starch  2  tablespoonfuls  sugar 

Put  all  these  ingredients  together  in  saucepan,  mix  well, 
then  put  on  stove  and  let  cook  slowly  until  thick.  When 
cold  serve  with  milk  or  cream. 

6.  Zabione 

2  cupfuls  milk  4  drops  vanilla 
^  cupful  sugar  2  eggs 

Put  all  together  in  saucepan  and  beat  well.  Put  on  back 
of  stove;  let  it  heat  and  cook  slowly,  stirring  often  until 
thick.     Serve  hot  or  cold. 

Other  recipes  which  may  be  used  for  children  are  as 
follows : 

7.  Spinagi 

^  peck  spinach  3  tablespoonful  butter 

1  tablespoonful  salt  f  tablespoonful  flour 

5  tablespoonfuls  cream  1  egg  yolk 

3  egg  whites 

Wash  and  cook  spinach  in  salt  and  one  tablespoonful  of 
water  for  twenty  minutes;  chop  fine.  Put  butter  and  flour 
in  saucepan.    Stir  while  heating,  then  add  chopped  spinach. 

450 


APPENDIX 

Cook  for  five  minutes  and  add  cream.  Add  well-beaten 
yolk  of  egg;  when  cool  add  well-beaten  whites,  then  place 
mixture  in  a  buttered  baking  dish  and  bake  for  ten  or 
fifteen  minutes.  Italian-cooked  vegetables  are  best  for 
children  in  this  form. 

8.  Lattuga  Informata  (Lettuce  Baked  in  Oven) 
Take  off  wilted  outside  leaves,  tie  up  heads  and  place  in 
baking  pan  with  two  cupfuls  of  soup  stock.     Bake  one  half 
hour.    Place  fork  under  heads,  remove,  and  serve  with 
stock  for  gravy. 

9.  Polenta  (Com  Meal  Mush) 
This  is  usually  eaten  with  meat  gravy  instead  of  milk. 
It  would  not  be  a  difficult  task  to  teach  children  to  eat  it 
with  milk. 

10.  Gnocchi  di  Semolina  (Indian  Meal) 
Often  called  farina  by  the  Italians.     Cooked  in  milk. 

11.  Canestrelli  (Tea  Cakes  or  Cookies) 
I  cupful  sugar  1  egg  yolk 

^  cupful  flour  ^  teaspoonful  vanilla 

Cream  together  sugar  and  butter;  add  well-beaten  egg 
yolk  and  vanilla;  then  enough  flour  to  make  a  firm,  smooth 
dough.    Roll  out  thin  and  cut  into  fancy  shapes. 

The  Jews 

Prohibited  Foods 

Prohibition  of  Animal  Foods. — ^Absolute  and  partial 
prohibitions: 

Unclean  animals  are  absolutely  prohibited.  Clean 
animals  are  all  quadrupeds  that  chew  the  cud  and  also 
divide  the  hoof.     All  others  are  regarded  as  not  clean. 

Products  of  animals  that  are  suffering  from  some  malady 
or  that  have  died  a  natural  death  or  had  eaten  poison  are 
regarded  as  terefah  and  may  not  be  used. 

All  animal  food  which  is  not  obtained  by  killing  in  the 
prescribed  manner  and  after  adequate  inspection  by  a  duly 
authorized  official  may  not  be  used. 

451 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Blood  was  regarded  by  the  ancient  Hebrews,  and  is  by 
many  primitive  peoples  to-day,  as  the  vital  part  of  the 
animal  which  must  be  given  back  to  God.  Fish  does  not 
come  under  this  category,  possibly  because  it  is  a  cold- 
blooded animal. 

**Fish  that  have  fins  and  scales — none  other — may  be 
eaten."  This  would  bar  all  shellfish,  such  as  oysters  and 
lobsters,  as  well  as  fish  of  the  eel  variety.  There  seems 
to  have  been  some  good  dietetic  reason  for  this,  as  the 
Eastern  waters  were  doubtless  often  polluted,  and  there 
may  have  been  cases  of  poisoning,  resulting  from  mistaking 
poisonous  water  snakes  for  eels. 

No  scavengers  or  birds  of  prey  are  to  be  eaten.  These 
are  regarded  as  unclean. 

The  suet  of  ox,  sheep,  or  goat  is  forbidden  (not  the  fat). 
Eat  of  birds  or  permitted  wild  animals  is  not  forbidden. 

An  egg  yolk  with  a  drop  of  blood  on  it  is  considered  as 
an  embryo  chick  and  is  forbidden. 

Prescribed  Modes  of  Preparing  Food 

The  following  partial  prohibitions  are  fully  as  important 
as  the  above: 

After  the  proper  cut  of  meat  is  secured  from  the  proper 
kind  of  animal  which  has  been  slaughtered  in  accordance 
with  Jewish  law,  it  is  to  be  soaked  half  an  hour  to  soften  the 
fiber  and  enable  the  juice  to  escape  more  readily  when  salted. 
(The  pan  used  for  this  purpose  may  not  be  used  for  any- 
thing else.)  The  meat  is  then  thoroughly  salted,  placed  pn 
a  board  which  is  either  perforated  or  fluted,  and  placed  in 
an  oblique  position  so  as  to  enable  the  blood  to  drain  off. 
It  is  allowed  to  remain  thus  for  one  hour,  after  which  time 
it  is  to  be  washed  three  times.  The  washing  is  for  the 
purpose  of  removing  all  the  salt.  This  process  is  called 
kashern,  and  is  regarded  as  very  important. 

Bones  with  no  meat  and  fat  adhering  to  them  must  be 
soaked  separately  and  during  the  saltmg  should  not  be 
placed  near  the  meat. 

Chops  and  steaks  may  be  broiled. 

The  heart  may  be  used,  but  must  be  cut  open  lengthwise 

452 


APPENDIX 

and  the  tip  removed  before  soaking.  This  enables  the 
blood  to  flow  out  more  freely.  Lungs  are  treated  as  is  the 
heart.  Milt  must  have  veins  removed.  The  head  and  feet 
may  be  kashered  with  the  hair  or  skin  adhering  to  them. 
The  head  must  have  the  brain  removed.  This  latter,  if 
used,  must  be  kashered  separately. 

To  kosher  fat  for  clarifying,  remove  the  skin  and  proceed 
as  with  meat. 

In  preparing  poultry  it  must  be  drawn  and  the  insides 
removed  before  putting  mto  the  water.  The  claws  must 
be  cut  off  before  ka^hering.  The  head  must  be  cut  off. 
The  skin  of  the  neck  must  be  either  turned  back  or  cut  so 
that  the  vein  lying  between  two  tendons  may  be  removed. 

Seething  a  kid  in  its  mother's  milk  is  forbidden. 

This  is  the  origin  of  the  prohibition  against  the  cooking 
of  meat  and  milk  together  or  of  the  eating  of  such  mixtures. 
This  rule  is  rigidly  adhered  to  and  in  its  present  application 
necessitates  the  use  of  a  complete  double  equipment  of 
dishes  and  utensils.  Since  this  rule  is  regarded  as  one  of 
the  most  important,  one  can  understand  why  such  sauces 
as  butter  sauces  are  refused  at  meals  with  meat.  This 
rule  occasions  the  home  economics  teacher  considerable 
trouble  in  planning  menus. 

Meat  and  fish  should  not  be  cooked  or  eaten  together, 
for  such  a  mixture  is  supposed  to  cause  leprosy.  The 
mouth  has  to  be  washed  after  eating  fish  and  before  meat 
may  be  eaten. 

In  addition  to  the  above  regular  daily  restrictions  there 
are  the  periodic  restrictions  that  the  teacher  should  know. 

Jewish  Holidays 

Sabbath. — No  food  may  be  cooked  on  the  Sabbath. 
This  means  that  all  cooking  for  both  days  is  done  on  Friday. 
This  need  has  led  to  the  development  of  foods  such  as 
Sabbath  kugel  or  sholend,  petshxii,  and  many  others. 

Passover. — During  Passover  week  no  leavened  bread  or 
its  product,  or  anything  which  may  have  touched  leavened 
bread,  may  be  used.  This  restriction  holds  for  eight  days. 
In  every  Jewish  home  a  complete  and  most  thorough  system 

30  ^^^ 


IMMIGRANT  HEALTH  AND  COMMUNITY 

of  cleaning  precedes  this  holiday.  No  corner  escapes  a 
scrubbing  and  scouring,  lest  a  particle  of  leaven  or,  what 
is  just  as  bad,  a  particle  of  food  which  may  have  touched 
leavened  bread,  should  be  found.  A  complete  new  set 
of  dishes  is  used  during  the  week.  Cutlery,  silver,  or  metal 
pots  may  be  used  during  this  holiday  if  properly  kashered 
or  sterilized.  The  usual  method  of  doing  this  is  to  plunge 
red-hot  coals  into  boiling  water  and  then  to  immerse  the 
desired  utensils.  These  or  any  other  Passover  utensils 
may  be  used  after  the  holiday  is  over  without  ve-kdshering, 
but  once  used  without  Passover  precautions  they  are  unfit 
for  Passover  use  unless  le-kashered.  In  actual  practice 
this  means  that  in  every  orthodox  Jewish  household  there 
are  four  sets  of  dishes — the  usual  set  for  meat  and  the  set 
for  milk  food,  in  addition  to  duplicate  Passover  sets.  The 
Passover  dishes  are  stored  away  very  carefully  lest  some 
leaven  come  near  them. 

Because  of  the  need  for  abstaining  from  leavened  bread 
during  Passover  many  interesting  dishes  have  developed, 
such  as  the  mazzah  klos  (dumplings)  soup,  cakes,  and 
puddings  made  of  the  Trvazzah  meal.  Almond  pudding  and 
cake  are  very  popular.  Almost  all  of  the  food  cooked 
during  this  holiday  requires  the  liberal  use  of  shortening 
or  fat,  with  great  danger  of  a  too  liberal  use  for  health, 
as  well  as  from  the  economic  point  of  view.  The  fat 
generally  used  is  either  goose  or  chicken  dripping  or  clari- 
fied beef  fat  other  than  suet. 

Fast  Days. — (a)  Yom  Kippur  (The  Day  of  Atonement). 
No  food  or  drink  may  be  had  for  twenty-four  hours, 
(b)  Fast  of  Esther.  This  precedes  the  Feast  of  Purim  and 
is  now  observed  only  by  the  very  pious.  The  feast  is 
universally  observed. 

Semifast  Days. — Eight  days  in  Ab.  For  nine  days  no 
meat  food  may  be  eaten  by  the  orthodox. 

Characteristic  Jewish  Dishes 

From  Spain  and  Portugal  comes  the  fondness  of  the 
modern  Jew  for  olives  and  the  use  of  oil  as  a  frying  medium. 
The  sour  and  sweet  stewing  of  meats  and  vegetables  comes 

454 


APPENDIX 

from  Germany.  The  love  of  pickles,  cucumbers,  and 
herrings  comes  from  Holland,  as  also  does  the  fondness  for 
butter  cakes  and  bolas  (grain  rolls).  From  Poland  the 
Jewish  immigrant  has  brought  the  knowledge  of  the  use  of 
lokscken  or  fremsel  soup  (cooked  with  goose  drippings), 
also  stuffed  and  stewed  fish  of  various  kinds.  From  Russia 
comes  kasha,  made  of  barley  or  grits  or  cereal  of  some  sort, 
which  is  eaten  instead  of  a  vegetable,  with  meat  gravy. 
Blintzes  are  turnovers  made  of  poured  batter  and  filled 
with  preserves,  or  cheese,  and  used  as  a  dessert.  Sholenty 
sometimes  called  kugel,  are  puddings  of  many  kinds,  such 
as  magan,  lokschen,  farfil  Zimes,  or  compotes  of  plums, 
prunes,  carrots,  and  sweet  potatoes,  turnips  and  prunes, 
parsnips  and  prunes,  and  prunes  and  onions,  are  all  pud- 
dings, and  come  from  Russia.  Zimes  of  apples,  pears, 
figs,  and  prunes  are  southern  Rumania,  Galician,  and 
Lithuanian  as  well. 

Soups  are  the  great  standby  of  the  poor.  Krupmck  is  a 
term  used  for  cereal  soups  made  of  a  cereal  like  oatmeal, 
with  potatoes  and  fat.  When  the  family  can  afford  it, 
meat  or  milk  is  added,  as  the  case  may  be.  This  is  the 
staple  food  of  the  yesbit  (schools  to  which  Jewish  boys  are 
sent  to  be  mstructed  in  Rabbinical  lore).  When  there  is 
neither  meat  nor  milk  in  the  soup  it  is  called  soupr  mii  nisht. 
This  is  really  supper  mit  nichts. 

Borsch  is  a  form  of  soup.  It  is  made  of  either  cabbage  or 
beet  root  and  rassel  (juice  derived  from  the  beet).  This  is 
made  by  the  addition  of  meat,  bones,  onions,  raisins,  citric 
acid,  sugar,  and  sometimes  tomatoes.  Eggs  are  added 
just  before  servmg  to  whiten  it.  This  is  called  farweissen. 
Gehakte  herring  is  really  a  salad  made  of  chopped  boned 
herring,  with  hard-cooked  eggs,  onions,  apples,  pepper,  and 
a  little  vinegar  and  sugar.  It  is  used  as  an  appetizer  in  the 
form  of  a  canape. 

Sabbath  kugel  or  sholend  is  a  dish  of  meat,  peas,  and 
beans,  sometimes  barley  or  potatoes  as  well,  which  is  placed 
m  the  oven  before  Sabbath  and  which  is  usually  eaten  hot 
on  the  Sabbath.    This  dish  is  sometimes  also  caUed  a 

shalet. 

455 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Petshai  or  drelies,  characteristic  of  south  Russia,  Galicia, 
and  Rumania,  is  a  calves'  foot  jelly  made  at  home.  (Com- 
mercial gelatin  is  prohibited.)  The  calves'  feet  are  cleaned 
by  first  singeing  ofif  the  hair.  They  are  then  kashered  and 
stewed  with  onions  and  seasonings  of  salt  and  pepper. 
Like  the  Sabbath  kugel,  this  is  placed  in  the  oven  the  day 
before  and  is  ready  hot  by  Sabbath  noon.  What  is  left  is 
freed  from  bone,  has  hard-cooked  eggs  and  vinegar  added, 
and  is  allowed  to  congeal.  This  forms  a  sort  of  aspic  which 
is  served  cold  in  the  later  afternoon. 

Strudel,  taken  from  the  Germans,  is  a  single-layered  jelly 
or  fruit  cake  and  takes  the  place  of  pie  as  a  dessert.  It  is 
usually  rolled.     The  dough  is  as  thin  as  tissue  paper. 

Teigachz  is  a  pudding  sometimes  called  kugel  or  sholend, 
and  may  be  made  of  rice,  noodles,  or  even  mashed  potatoes. 
These  usually  have  some  drippings,  eggs,  and  flavoring 
added. 

Gebrattens  is  pot  roast  and  is  usually  accompanied  by 
kasha,  though  it  is  often  served  with  potatoes  which  have 
been  cooked  with  the  pot  roast.  These  are  really  stewed 
to  a  golden  brown.  Onions  are  always  an  important 
ingredient. 

Almond  pudding  is  a  favorite  because  it  requires  neither 
meat  nor  butter  and  can  therefore  be  eaten  at  either  type 
of  meal.  It  is  made  of  almonds,  eggs,  sugar,  cinnamon, 
and  lemon  rind,  and  baked. 

The  obstacles  to  the  use  of  meat  have  developed  a  taste 
for  fish,  as  well  as  for  cheese  and  milk  products.  Since  fish 
is  not  a  warm-blooded  animal,  it  may  be  eaten  in  con- 
junction with  milk  and  milk  products.  (This  is  an  added 
reason  for  its  popularity.  The  celebration  of  the  Sabbath 
and  the  eating  of  fish  have  always  been  associated.)  Mrs. 
Schapiro  declares  that  "from  no  orthodox  table  is  fish 
absent  at  one  or  more  of  the  Sabbath  meals,  however 
difficult  it  may  be  to  procure.  In  inland  countries  like 
Poland  the  Jews  are  limited  to  fresh-water  fish.  I  have 
known  people,  who  could  barely  afford  bread  during  the 
week,  to  pay  as  much  as  forty  or  even  fifty  cents  per  pound 
for  their  Sabbath  fish.     Salmon  is  a  favorite  kind  of  fish. 

456 


APPENDIX 

This  is  fried,  white  stewed,  or  brown  stewed.     Smoked 
salmon,  pickled  herrings,  and  pickled  pickerels  are  served 
as  appetizers  by  the  Russian  Jews.     Most  characteristic  of 
all  the  fish  dishes,  perhaps,  is  the  gefiltefisK  for  which  carp, 
whitefish,  and  pike  are  most  generally  used.     Part  of  the 
flesh  of  the  fish  is  removed  and  chopped  with  onions, 
bread  crumbs,  seasonings,  and  egg.     The  mixture  is  re- 
turned to  the  fish,  which  is  then  cooked  or  stewed  with 
more  onions  and  a  large  amount  of  pepper  for  several  hours 
at  a  low  temperature.     The  long,  slow  cooking  develops  the 
flavor  of  the  different  kinds  of  fish,  which  blend  and  form  a 
most  palatable  dish.     While  Jewish  fish  dishes  form  excel- 
lent appetizers,  or  even  entrees,  I  do  not  thmk  they  are 
desh-able  as  the  mam  dish  of  the  meal,  because  of  the  high 
seasonmg.     For  this  reason  they  are  particularly  bad  tor 

children.  ...  ^^  .  , 

12.  Krupnick 

1  cupful  roUed  oats  1    tablespoonful    goose    or 

3  eupfuls  milk  chicken  fat 

6  potatoes  cut  up 

Boil  all  together  three  hours. 

13.  Borsch  (Russian  Beet  Soup) 

To  have  a  good,  wholesome  horsch  with  a  natural  sour- 
ness you  have  to  make  what  is  known  as  rassel.    Take 
three  bunches  red  beets,  peel  and  cut  in  halves    wash 
Put  into  a  wooden  or  earthenware  jar.     Cover  with  tepid 
soft  water  and  set  in  a  warm  place,  covermg  jar  with  towe  . 
In  four  days  rassel  will  be  ready.     A  crust  of  real  dark 
bread  improves  rassel    When  rassel  is  ready  put  it  mto  a 
ceUar  or  other  cool  place  to  prevent  the  process  of  fermenta- 
tion from  continuing.     To  make  horscK  make  a  good  con- 
somme with  meat  and  as  many  vegetables  as  are  on  hand. 
When  consomm^  is  ready,  bake  a  few  raw  beets  m  skms; 
when  ready  cut  them  fine  and  sprmkle  with  a  little  sugar 
Add  to  strained  consomme  and  add  some  of  the  rassel 
to  taste.     Boil  once  and  serve  with  sour  cream. 
14.  Almond  Omelet 

i  cupful  almonds  4  eggs 

4  tablespoonfuls  cream 
457 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Blanch  the  almonds,  chop  fine,  and  pound  smooth.  Beat 
the  eggs,  add  the  cream,  and  turn  into  a  hot  pan  in  which 
one  tablespoonful  of  butter  has  been  melted.  When  the 
omelet  is  set,  sprinkle  the  almonds  over  it,  fold  over,  and  serve. 

15.  Bitki  (Hamburg  Steak) 

Take  two  cupfuls  of  clear  beef  chopped  and  two  cupfuls 
of  bread  crumbs  that  have  been  soaked  in  a  little  water, 
leaving  them  quite  moist;  mix  thoroughly,  season  with 
pepper  and  salt,  and  shape  into  individual  cakes.  Fry  as 
Hamburg  steak. 

Both  kascha  and  schavel  are  dishes  that  can  be  recom- 
mended and  enjoyed.     They  are  made  in  the  following  way : 

16.  Kascha 
Made  of  whole  buckwheat  grain  or  fine  barley  or  whole 
oats  or  millet  (to  be  washed  in  many  waters  before  using). 
Take  one  pound  of  grain  and  rub  through  it  one  whole 
egg.  Dry  thoroughly  on  a  frying  pan,  stirring  to  prevent 
burning.  When  dry  put  into  an  earthenware  dish  with 
cover.  Cover  with  boiling  water.  Add  salt  to  taste  and 
butter  size  of  egg.  Bake  in  moderate  oven  until  done 
(from  two  to  three  hours).  Watch  to  prevent  burning. 
When  edges  get  too  dry  add  boiling  water,  pouring  along 
edges.     Favorite  dish  for  peasant. 

17.  Schavel  (Sorrel  Soup) 
Chop  fine  one  pound  sorrel,  one  pound  spinach,  put  in  a 
pot  and  cook  in  boiling  water  (open  pot),  adding  salt  to 
taste.  W^hen  greens  are  tender,  in  about  one  half  hour, 
take  two  yolks  of  eggs  in  a  bowl,  rub  with  a  little  salt,  and 
stir  hot  mixture  into  the  yolks  drop  by  drop  to  prevent 
curdling  of  yolks.  Set  out  to  cool.  When  cold  put  on  ice. 
To  serve,  put  into  plate  a  tablespoonful  of  sour  cream, 
and  add  cold  soup,  stirring  cream.  Add  chopped  hard- 
boiled  eggs.     Favorite  dish  for  summer. 

18.  Scrambled  Eggs  with  Potatoes 
3  eggs  3  tablespoonfuls  milk 

3  potatoes  J  teaspoonful  salt 

1  large  onion  Pinch  pepper 

1  tablespoonful  chicken  fat 
458 


APPENDIX 

Cut  up  potatoes  and  onions  and  brown  in  pan  with  chicken 
fat.  Add  well-beaten  eggs,  milk,  salt,  and  pepper.  Stu: 
until  scrambled. 

Armenians,  Syrians,  Turks,  and  Greeks 
19.  Matzaun  or  Yoghourt 

2  quarts  milk  1  tablespoonful  old  matzaun 

Heat  milk  over  a  slow  fire  until  it  starts  to  boil;  set 
aside  to  cool  until  blood-warm.  Add  one  tablespoonful 
of  old  matzaun  to  start  fermentation.  Cover  vessel  with 
blanket  to  keep  the  milk  warm  durmg  the  process  of 
fermentation.  , 

In  from  two  to  three  hours  it  will  be  done.  It  may  be 
served  hot  or  cold,  and  some  people  add  sugar. 

20.  Ashoureh 
1  pound  wheat  h    to    1    teaspoonful   rose- 

\h  pounds  sugar  water 

i  cupful  seedless  raisins  4  cupful  hazelnuts,  chopped 

h  cupful     pistachio     nuts,       i  cupful  walnuts,  chopped 
peeled  i  cupful  almonds,  chopped 

1  to  2  pinches  cinnamon,  powdered 

Soak  the  wheat  in  plam  water  for  ten  or  twelve  hours, 
then,  after  washing  well,  boU  m  newer  water,  twice  of  its 
measure,  until  it  cracks.  In  a  separate  vessel  boil  the 
sugar  m  an  equal  quantity  of  water,  until  two  thirds  ot  it 
remams  To  this  add  the  raisms  and  the  pistachio  nuts. 
Then  pour  these  all  m  the  boiled  wheat  and  contmue 
boilmg  a  while  longer.  AVhen  this  is  done  take  away  from 
the  fire  and  add  the  -rosewater.  Then  chop  weU,  add 
hazelnuts,  walnuts,  and  almonds;  roast  a  little  m  a  pan 
on  a  moderate  fire  and  spread  over  the  boiled  wheat  mixture, 
meanwhile  siftmg  on  the  powdered  cinnamon. 

21.  Kolva 

1  pound  wheat  h  cupful  almonds,  chopped 

i  cupful  flour  h  cupful  walnuts,  chopped 

1  cupful  sugar  1     cupful     fancy      candy, 

i  cupful  raisms,  seedless  mixed 

"^  459 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Soak  the  wheat  in  water  for  ten  or  twelve  hours,  wash  well, 
and  boil  in  newer  water,  but  take  away  from  the  fire  before 
it  cracks.  Strain  and  then  spread  on  some  white  muslin 
overnight.  Then  roast  the  flour  in  a  pan  by  itself  until 
light  brown,  and  when  sufficiently  cold  add  the  sugar,  also 
the  almonds  and  the  walnuts,  which  should  be  well  chopped. 
Add  this  mixture  to  the  boiled  wheat,  and  mix  in  also  the 
spiced  fancy  "grape  shot"  candy.     (Serve  cold.) 

22.  Wishneh  (Cherry  Preserve) 
2j  pounds  sugar  1|  pounds    sour    cherries, 

1  pint  plain  water  freed  from  the  stones 

1  teaspoonful  lemon  juice 

Boil  the  sugar  in  the  water  over  a  moderate  fire  until  it 
gets  cream  thick,  then  add  the  sour  cherries  (without  the 
stones),  also  the  lemon  juice;  after  a  little  boiling  take  away 
from  the  stove  and  cool  before  placing  in  jars. 

Note:  Retchel  can  be  prepared  from  all  kinds  of  berries 
and  fruits,  especially  from  figs,  pineapple,  and  even  pump- 
kin, in  same  manner  as  described  above. 

23.  Pilaf  (Turkish) 
5  cupfuls  stock  2  tablespoonfuls  butter 

2  cupfuls  rice  Salt  and  pepper  to  taste 

In  a  deep  vessel  fry  well  the  washed  rice  in  the  butter, 
then  add  the  stock.  When  nearly  done  remove  to  back  of 
stove  to  cook  slowly.  Cover  with  a  piece  of  muslin  under 
the  lid,  letting  it  fall  a  little  over  the  brim  to  prevent  the 
steam  from  falling  back  into  the  kettle.  After  ten  minutes 
stir  the  rice  lightly  with  a  perforated  spoon,  then  place  over 
hot  oven  until  moisture  is  evaporated  and  rice  is  almost  dry. 
(Cracked  wheat  may  be  used  instead  of  rice.) 

24.  Herissa  (Armenian) 
1  pound  lamb  or  chicken      2  tablespoonfuls  butter 
10  cupfuls  stock  3  pinches  cinnamon 

Pepper  and  salt  to  taste 

Take  lamb  or  chicken  meat  without  bones,  boil  for  an 
hour  or  longer,  shred  into  fine  thready  pieces  with  your 
fingers.     Take  the  special  wheat  prepared  for  this  purpose 

460 


APPENDIX 

and  soak  in  water  from  eight  to  ten  hours,  then  boil  in  one 
haK  the  broth  of  the  chicken  or  lamb,  gradually  addmg  the 
rest  of  the  broth.  During  the  process  of  boiling  it  is 
necessary  to  stir  and  pound  the  mixture  contmually  with  a 
wooden  spoon.  When  serving  in  plates  pour  over  each 
share  hot  butter  and  powdered  cmnamon  to  taste. 
25.  Lohano  Basidi-Kelom 

1  pound  of  fat,  beef,  mutton        2  ripe  tomatoes   (or  3  to 

or  lamb  4    tablespoonfuls    of 

3  pounds  cabbage  canned  tomatoes) 

2  dry  onions,  medium  3  cupfuls  broth    (or  plam 

Sah  and  red  pepper  to  taste  water) 

Cut  the  cabbage  into  egg-sized  pieces  and  the  meat 
into  one  haK  the  size  of  the  cabbage  pieces.     Also  chop 
coarsely  the  onions  and  put  them  all,  alternately,  mto  a 
suitable  vessel.     Season  with   salt  and   the  red   pepper. 
Then  after  adding  the  cut  tomatoes  and  the  broth  boil 
on  a  moderate  fii-e  until  the  meat  and  cabbage  become  very 
tender.    (It  is  better  to  serve  this  basidi  at  least  six  to  eight 
hours  after  cooking,  when  it  should  be  reheated.) 
26.  Tureli  Ghuvedge 
1  pound  of  fat,  mutton  or        1  bunch  parsley 
lamb  i  bunch  mint 

1  pound  eggplant  5  to  6  strips  celery 

A  pound  green  beans  3    to    4    ripe    and    unripe 

2  dry  onions,  medium  tomatoes 

Salt  and  red  pepper  to  taste 

Clean  aU  the  vegetables  properly  and  cut  them  into  small 
sizes;  do  the  same  with  the  meat.  Then  put  aU  m  a  deep, 
flat  pan  or  a  deep  earthen  vessel  and,  after  seasonmg  the 
whole  to  taste,  place  m  a  moderately  hot  oven  until  weU 
done.  It  is  not  necessary  to  use  any  broth  or  plam  water 
with  this  basidi,  as  the  ingredients  will  discharge  enough 
water  to  be  cooked  in. 

27.  Patlijam  Beoregh  (Eggplant  in  Omelet  Style) 

1  eggplant,  medium  2  to  3  tablespooi^uls  hard 
Butter  in  quantity  to  fry  cheese,  grated 

^-ith  2  bunch  parsley 

2  eggs  Salt  and  pepper  to  taste 

461 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Slice  the  eggplant  in  less  than  one-half-inch  disks  and 
fry  slightly  with  butter  in  a  large,  flat  pan.  Then  make  a 
mixture  of  the  eggs,  the  grated  cheese,  and  very  finely 
cut  parsley  and,  after  seasoning  it  to  taste,  pour  it  over 
each  piece  of  the  eggplant,  and  continue  frying  until  brown 
on  both  sides. 

28.  Spinache 

2  quarts  spinach  1  cupful  broth  (or  milk) 

1  tablespoonf  ul  flour  2  to  3  slices  bread  (stale) 

2  tablespoonfuls  butter  Salt  and  pepper  to  taste 

Clean  the  spinach,  cut  into  pieces,  wash  well,  boil  for 
ten  minutes,  and  put  through  cold  water.  Then  fry  the 
flour  for  ten  minutes  in  the  butter;  to  this  add  the  spinach, 
also  one  half  of  the  broth.  After  boiling  this  mixture  for 
five  to  eight  minutes,  pour  in  the  rest  of  the  broth,  stir 
slowly,  and  continue  boiling  for  ten  minutes  longer.  (Serve 
this  hot  with  a  little  hot  butter  poured  over  it.) 

The  stale  bread  slices  may  be  cut  into  square  pieces  and 
fried  in  butter  and  arranged  over  the  spinach.  The  broth 
may  be  replaced  with  milk. 

29.  Tazeh  Fassculia  Yaghli  (Green  Beans  with  Olive  Oil) 
1  quart  green  beans  2  ripe  tomatoes  (or  3  to  4 

3  dry  onions,  medium  tablespoonfuls    of 
1  green  pepper,  medium                 canned  tomatoes) 

3  tablespoonfuls  olive  oil        Salt  and  pepper  to  taste 

Clean  and  trim  the  beans,  splitting  them  lengthwise, 
crush  with  some  salt,  and,  after  washing,  arrange  them  in  a 
suitable  vessel.  Slice  over  this  the  onions  and  the  green 
pepper.  Also  add  the  juice  of  the  tomatoes.  Season  to 
taste  and,  after  pouring  in  the  olive  oil,  boil  on  a  moderate 
fire  for  ten  to  fifteen  minutes,  when  one  half  of  plain  water 
should  be  added,  and  then  left  over  a  slow  fire  to  simmer 
until  done.     (Serve  hot  or  cold.) 

30.  Khiyar  Dolma  (Stuffed  Cucumbers) 

Pare  eight  to  ten  cucumbers  of  medium  size,  dig  out 

their  seedy  parts  with  the  aid  of  a  narrow  and  pointed  knife, 

stufif  with  the  dolma  mixture,  and  after  piercing  each  one 

with  a  fork  arrange  in  a  suitable  pan,  side  by  side.     Add 

462 


APPENDIX 

two  or  three  ripe  tomatoes,  cut  into  small  pieces  (or  three 
to  four  tablespoonfuls  of  camied  tomatoes),  and  then 
pour  over  one  cupful  or  more  of  broth  or  plain  water.  Cook 
either  on  a  slow  fire  or  in  a  moderately  hot  oven. 

Dolma  mixture  is  made  of  equal  parts  of  cooked  rice  and 
twice-ground,  cooked  meat,  seasoned  with  parsley,  salt, 
and  pepper 

Dressing:  terhieh — made  of  one  beaten  egg  and  the 
juice  of  one  lemon  mixed — may  be  added  to  the  whole,  after 
blending  the  mixture  first  with  part  of  the  dolma  gravy. 
(Serve  hot.) 

31.  Tzouvatzegh  (Armenian  Egg  Milk  Toast) 

6  to  8  slices  bread,  dry  (or      Butter  in  quantity  required 

toasted)  for  frying 

1  cupful  milk  3  or  4  eggs 

Sugar  to  taste 

Dampen  the  dry  bread  with  the  milk  and,  after  dipping 
into  the  beaten  eggs,  fry  in  smoking-hot  butter  on  both 
sides.  Some  prefer  only  eggs  and  omit  the  milk;  others 
use  the  milk  with  the  beaten  eggs  mixed,  the  result  of  both 
methods  being  similar.  (Serve  with  sugar  or  syrup  if 
desired.) 

32.  Matzaun  with  Eggs 

1  cupful  matzaun  4  eggs 

4  to  5  bulbs  garlic,  pressed      1  tablespoonful  butter 

Salt  and  pepper  to  taste 

Mix  the  juice  of  the  garlic  with  the  matzaun  and  hold 
ready  in  a  large,  flat  plate.  Then  break  the  eggs  into 
boiliQg-hot  water,  and  let  boil  for  five  or  six  minutes, 
regular  dropped-egg  style,  after  which  time  take  them  out 
with  the  aid  of  a  perforated  spoon  and  arrange  in  the 
plate  over  the  matzaun.  This  done,  pour  over  the  whole 
the  butter,  which  should  be  smoking  hot.  Season  to  taste 
and  serve  at  once. 

33.  Sudeli  Youmourta 

5  cupful  sugar  4  eggs 

2  cupfuls  milk  1  orange,  skinned 

Salt  and  pepper  to  taste 
463 


IMMIGRANT  HEALTH  AND  COMMUNITY 

Take  a  saucepan,  put  the  milk  in,  and  break  the  eggs 
into  it.  Add  the  orange,  cut  into  pieces.  Season  to  taste 
and  stir  well;  then  place  the  saucepan  in  a  steamerful  of 
boUing  water.  Cook  this  on  a  moderate  fire  until  the 
mixture  is  fairly  thick.  Spread  over  it,  lightly,  some 
burnt  sugar,  and  serve. 

The  Poles  and  Other  Slavic  Peoples 

34.  Kieselle 
One  quart  of  berries  or  grapes  washed  well  and  drained. 
Cover  berries  with  cold  water  and  cook  until  soft.  Strain 
through  cheesecloth.  Add  sugar  to  taste  and  set  to  cook; 
when  boiling  add  two  or  three  large  tablespoonfuls  of  corn- 
starch.    Set  to  cool.     Serve  with  cream. 

35.  Ovsyanka 
One  quarter  pound  whole  or  cracked  oats  and  enough 
water  for  five  or  six  plates  of  soup.  Boil  with  one  onion 
when  grain  is  soft,  stram,  add  a  lump  of  butter  and  a  little 
milk;  serve  with  croutons.  A  few  dry  mushrooms  chopped 
fine  (well  washed)  add  to  flavor  and  taste  of  soup. 

36.  A  Cold  Soup,  or  Floating  Island 
Boil  a  quart  of  milk.  Beat  the  whites  of  eggs  stiff  and 
add  one  tablespoonful  of  sugar.  Drop  the  whites  off  the 
spoon  into  the  boiling  milk.  When  the  mixture  boils  re- 
move the  whites  with  a  perforated  spoon  and  put  into  a 
bowl.  Take  the  three  yolks  and  rub  until  white  with  one 
half  glass  of  sugar.  Dilute  with  one  quarter  glass  of  cold 
milk  and  add  to  boiled  milk,  stu-ring  constantly  so  yolks 
don't  curdle.  Keep  on  slow  fire  until  somewhat  thick, 
but  not  boiling — add  for  flavor  either  cinnamon  or  vanilla. 
Set  on  ice  and  serve  with  the  whites.  This  makes  a  good 
dessert. 

37.  Flaxseed  oil  with  a  small  amount  of  lemon  juice  is  a 
favorite  salad  dressing. 


INDEX 


Accident  Prevention : 

For  immigrants,  352-357 
Adams,  Samuel  Hopkins,  163 
Advertising : 

Quack,  147-163,  165-166 
African : 

Insanity,  39 

Malnutrition,  38 
Age: 

Death  rate,  47 

Morbidity,  35 

Nativity  distribution,  42 
Agriculture : 

Workers,  124 
Akron,  Ohio : 

Health  work,  290 
Alabama : 

Midwifery,  205 
Albany,  New  York: 

Health  work,  377 
Alcoholism : 

Among  foreign  born,  39, 48 

Among  Irish,  56 
American  Association  for  La- 
bor Legislation,  401 
American  Association  of  For- 
eign-language News- 
papers, 169-170 
American  Association  of  Hos- 
pital  Social   Workers 


American   Dietetic   Associa- 
tion, 312,  434 
American  Hospital  Associa- 
tion, 277,  430,  434 
American   Medical   Associa- 
tion, 163,  434 
American  Medical  Directory, 

121,  135,  305 
American  Public  Health  As- 
sociation,    296,     431, 
437 
American  Red  Cross : 

Health  program,  413,  435- 

436 
*' Housing  m  Italy,'*  90 
American  Social  Hygiene  As- 
sociation, 297,  435 
Americanism : 

Definition,  23 
Americanization : 
Agencies 

Cleveland  Committee, 
296,  417 
Definition,  8-10,  243,  429, 

446-448 
Factors,  440-443 
Instruments,  276 
Theories  of  procedure 
Big  Stick,  10-15 
Laissez-faire,  15-18 
The     Democratic,     18- 
23 


465 


IMMIGRANT  HEALTH  AND  COMMUNITY 


Amoskeag    Manufacturing 
Company : 

Accident  prevention,  355 
Arabic: 

Quacks,  150 
Arizona: 

Midwifery,  205 
Arkansas : 

Midwifery,  205 
Armenian: 

Diets  for  sick,  269-270 

Documents,  279 

Food  habits,  264-268 

Heritages,  122 

In  Fresno,  California,  75 

Midwives,  212 

Quacks,  150 
Armstrong,  Donald  B.,  54, 

421-428 
Auerbach,  Samuel  M.,  xxvi 
Austria: 

Infant  mortality,  185 
Austrian : 

Birthrates,  185 

Death  rates,  45,  47,  61 

Infant  mortality,  186 

Midwives,  197,  212 

B 

Baker,  S.  Josephine,  200,  203 
Balch,  Emily  G.,  116 
Baltimore : 

Dispensaries,  331 

Quack  advertising,  168 
Beaumont,  Texas: 

Health  work,  378 
Belgium: 

Midwifery,  199 
Benefit  Societies,  92-111 

In  industry,  357-360 


Bimanski,  Francis  A.,  292-294 
Birth  rates: 

Foreign  born,  184-187,  439 
Boarders: 

In  immigrant  households, 
81-82,  364 
Boards  of  Health: 

Control  of  midwife,  206 
Sanatorium  report,  313 
Boas,  Franz,  438-439 
Bohemian: 
Birth  rate,  186 
Boarders,  81 

Death  rates,  44, 48,  51, 186 
Food  habits,  248 
Geringer  Press,  168 
Health  care,  331 
Phrase  book,  291 
Physicians,     in     Chicago, 

136-137 
Quacks,  150 
Boston : 

Benefit  societies,  100 
Committee     on     Prenatal 
Care   and   Obstetrics, 
233 
Death  rates,  47,  5Q 
Dispensary 

Nativity  of  clientele,  330 
Jews  using,  332 
The  Maverick,  386 
Lying-in  Hospital,  229 
Midwifery,  196 
Physicians,  foreign-born, 

137 
Quacks,  149 
Bowling     Green     Neighbor- 
hood Association,  381 
Bridgeport,  Connecticut: 
Health  work,  379 


466 


INDEX 


Bright's  Disease: 
Death  rate,  48 

Brockton,  Massachusetts: 
Infant  death  rate,  62 

Brown,  Adelaide,  201 

Brown,  Walter  H.,  xxvi 

Buffalo,  New  York: 
Health  centers,  385 
Health  work,  290,  300 
Midwifery,  206 
Polish  hospitals,  322 

Bulgaria: 

Infant  mortality,  185 

Bureau  of  Labor  Statistics, 
xxvi: 
Family  incomes,  394 
Sickness  of  wage  earners,  28 

Burgess,  Ernest  W .,  29 


California : 
Climate,  253 

Industrial  health  work,  345 
Midwifery,  198,  201-202 
California  Commission  of  Im- 
migration and  Hous- 
ing, 75-76,  177,  367 
Canadian : 
Births  attended  by  mid- 
wives,  197 
Death  rate,  47,  51,  186 
Cannon,  M.  Antoinette,  xxvi   Cleveland,  Ohio: 
Cedar  Rapids,  Iowa : 

Quack  advertising,  168 
Chadsey,  Mildred,  89 
Chapin,  Charles  V.,  212,  218 
Charity  Organization  Society 

of  New  York,  301 
Chicago : 

Annual  births,  232 

467 


Benefit  societies,   103-107 
Department     of     Health, 

177 
Dispensaries,  331 
Hospitals 

Cook  County,  292 
Jewish  "Kosher,"  322 
Lying-in,  229,  230 
Michael  Reese,  322 
Polish,  322 
Industrial     health     work, 

345 
Midwifery,  198 
Physicians'  testimony,  138, 

140 
Physicians,  foreign-born, 

135-136,  138 
Quacks,  149 

Advertising,  167-168 
Children's  Bureau: 

Infant    mortality   studies, 
60-63,  83-84,  189, 198 
Report  on  midwifery,  212, 
250 
Church : 

Benefit  societies,  95,  97-99 
Cincinnati,  Ohio: 
National  Social  Unit,  387- 
390,  408,  415 
Circulatory  Disease: 
Death  rate,  48 


Americanization   Commit- 
tee, 296,  417 
Dispensaries,  311 
Health  centers,  384-385 
Industrial  health  work,  345 
Polish  hospitals,  322 
Visiting   Nurses'   Associa- 
tion, 291 


IMMIGRANT  HEALTH  AND  COMMUNITY 


Clinic: 

Factory,  358 
Food,  339 
Industrial,  4!'^4i-4<25 
Medical,  425-426 
Of  labor  unions,  359 
Prenatal,    221-223,     422- 

423 
Public  health,  327 
School,  423-424 
Colorado : 

Industrial  health  work,  345 
Colorado  Fuel  &  Iron  Co. : 

Health  plan,  371 
Committee  on  the  Prevention 

of  Tuberculosis,  301 
Community : 

Administration    of    health 
work,    404-413,    419- 
428 
Hospital  service,  323-325 
Industrial     health     work, 

371-375 
Maternity  care,  233-246 
Medical  service,  342-343 
Physicians  per  population, 
136 
Connecticut : 
Midwifery,  206 
Physicians,  138 
Constipation : 
Diets  for 

Armenian,  269 
Greek,  269 
Italian,  256 
Jewish,  262 
Polish,  273 
Slavic,  273 
Syrian,  269 
Turkish,  269 


"Contract  System": 

In  industrial  health  work, 
369-370 
Co-operation  for: 

Immigrant    health    work, 
414-417 

Maternity  care,  243-245 
Cramp,  Arthur  J.,  174 
Croatian : 

Benefit  societies,  104-105 

Boarders,  81,  364 

Heritages,  115-116 

Quacks,  150 
Czecho-Slovaks : 

Benefit  societies,  102,  105 

D 

Danish: 

Newspaper 
Den  DansJce  Pioneer,  167 
Davenport,  C.  B.,  442-443 
Davis,  Janet  Hayes,  xxvi 
Davis,  Michael  M.,  Jr.,  380 
Davis,  William  A.,  47,  56 
Davis  and  Warner,  326 
Death  rates: 

Cause,  35,  43-63,  184-187 

Infant,  214 

Native   and   foreign-born, 
440 
Delaware : 

Midwifery,  205 
Democracy : 

Americanization  in,  18-23 
Dempsy,  Mary  V.,  62 
Denmark : 

Infant  mortality,  185 

Midwifery,  200 
Denver : 

Health  work,  377 


468 


INDEX 


Departments  of  Health: 
Controlling        medical 

quacks,  179-183 
Questionnaire  on  housing, 

8o-89 
Use  of  foreign-language  lit- 
erature, 289 
Work   with  foreign   born, 
376-385 
Department  of  War: 
Examination     of     drafted 

men,  31-34 
Quack  advertising,  159 
Detroit,  Michigan: 
Health  work,  287 
Home  Nursing  Association, 

188,  198,  201 
Maternity     survey,     183, 

188,  201 
Midwifery,  198 
Polish  hospitals,  322 
Quacks,  150 

Semet  -  Solvay    Company, 
353 
Diabetes : 
Diets  for 

Armenian,  269-270 
Greek,  269-270 
Italian,  257 
Jewish,  262 
Polish,  273 
Russian,  273 
Slavic,  273 
SjTian,  269-270 
Turkish,  269-270 
Diets : 

Immigrant,  246-279,  311- 
313 
Digestive  Diseases: 

Death  rate,  48 
31  469 


Disease  {see  Sickness) 
Dispensaries,  326-342 
Definition,  176 
Licensing,  176-177 
Socialization,  338-339 
District  of  Columbia: 
Midwifery,  205,  218 
Drugstore : 

Relation  to  foreign  bom, 
131-133 
Dublin,  Louis  I.,  46-47,  49, 

51 
Duluth,  Minnesota: 

Foreign  physicians,  136 
Duke,  Emma,  62,  83-84, 189, 

198 
Duncan,  Beatrice  Sheets,  62, 
84 

E 

Eastman,  P.  R.,  59,  185 
East  Orange,  New  Jersey: 

Malnutrition,  38 
Elkus,  Abram  L,  79-80,  88 
Emmons  2d,  A.  B.,  210 
Endicott,  Johnson  &  Co.: 

Health  work,  360 
England: 

Health  study,  362-363 

Midwifery,  200 
English : 

Births   attended   by  mid- 
wives,  197 

Death  rates,  45, 47-49, 51, 
186 

Malnutrition,  38 

Phrase    book    for    health 
work,  291-292 
Enuresis : 

Diets  for  Jewish,  261 


IMMIGRANT  HEALTH  AND  COMMUNITY 


Erie,  Pennsylvania: 

Health  work,  378 
Europe: 

Physicians,  121 

F 

Fairchild,  Henry  Pratt,  114 
Finnish: 

Physicians,  136 

Quacks,  150 
Fitchburg,  Massachusetts: 

Health  work,  288 
Florida: 

Midwifery,  205 
Ford,  Henry,  354 
Foreign  born: 

Midwifery,  197-203 
Foreign  language  in: 

Accident  prevention,  355- 
356 

Diet  work,  276-277 

Health  work,  289-294 
Foreign-language       newspa- 
pers: 

Quack    advertising,    147- 
153,  164-170 
Foresters : 

Benefit  societies,  94 
Fosdick,  Raymond,  x 
Framingham,  Massachusetts, 
Study,     54-55,     408, 
421-428 
France : 

Infant  mortality,  185 

Midwifery,  199 
Fraternal  Order  of  Eagles: 

Benefit  societies,  94 
French: 

Death  rates,   44,  48,   51, 
186 


470 


Newspaper 

Le  Courier  Franco-Amir' 
icain,  167 
Quacks,  149,  150 
French-Canadian : 

Boarders,  81 
Fresno,  California: 

Immigrant  colony,  75-76 

G 

Galicia: 

Jewish  diets,  260 
Gay,  Edwin  F.,  x 
Georgia: 

Midwifery,  205 
German : 

Benefit  societies,  105 

Births  attended  by  mid- 
wives,  197 

Boarders,  81 

Death  rates,  44-51,  54, 186 

Health  care,  333 

Health  centers,  387 

Infant  mortality,  185 

Insanity  among,  39 

Malnutrition,  37-38 

Mid  wives,  212 

Phrase    book    for    health 
work,  291 

Quacks,  150 
Germany: 

Infant  mortality,  185 

Jewish  diets,  259 

Midwifery,  197 
Glen,  John  M.,  x 
Goodrich  Company: 

Health  work,  360 
Goodyear    Tire    &    Rubber 
Co.: 

Employee  housing,  363 


INDEX 


Government: 

Immigrant's    relation    to, 
121-122 
Great  Britain: 

Health-insurance  legisla- 
tion, 403 
Infant  mortality,  185 
Greeks : 

Benefit  societies,  93,  101- 

102,  105 
Boarders,  82,  364 
Diets  for  sick,  268-270 
Food  habits,  264-267 
Health  care,  331 
Heritages,  114 
Newspapers 
Atlantis,  167 
Star,  167 
Physicians,  135,  137 
Quacks,  150,  160-161 
Guilfoy,  William  H.,  44-45, 
49-50,  54,  60 

H 

Haasis,   Bessie   Anamerman, 
xxvi 

Harris,  Louis,  359 

Harvard  Medical  School  xxvii 

Health: 

Co-operation  for,  414-417 
Effect  of  occupation,  124 

Health  Centers  m,  328 
Buffalo,  386-387 
Cleveland,  384-385 
New  York,  380-384,  405 

Health  Insurance: 

In  medical  care,  401-404 
Health  work: 

Administration,  404-406 
Localization  of,  299-302 


Factors,  3-10,  126-128 
Field  agent,  283-304 
Immigrant,  330-334 
Diets,  274-279 
Limitations,  393-401 
Resources,  129-142 
Industrial,  344-375 
Problems,  117-120 
Public,  376-385 
Significance,  117-120, 439- 

448 
Small  community,  419-428 
Training,  432-433 
Henry  Street  Settlement: 

Health  study,  34-36 
Heritages  {see  Immigrant) 
Holland : 

Jewish  diets,  259 
Midwifery,  199 
Homes : 

Industrial     health     work, 

360-362 
Medical  resources,  130-131 
Homestead,  Pennsylvania: 

Quack  advertising,  168 
Horak,  J.,  94,  104-107 
Hospital: 

Cook     County,    Chicago, 

292 
Health  care,  101-102,  333 
Immigrant  attitudes,  121, 

306-311 
Infant  death  rate,  Newark, 

214 
Licensmg,  176-177 
Localization,  323 
Maternity,  219-222 
Socialization,  318-321 
Work  for  immigrants,  305- 
325 


471 


IMMIGRANT  HEALTH  AND  COMMUNITY 


Housing : 

Effect  on  health,  82-89 

Factors,  72-75,  89-91 

For  foreign  born,  70-80 

Fresno,  Cahfornia,  75-76 

Government,  78 

Relation  to  industry,  362- 
371 
Howard,  Clarence  H.,  354 
Hungarian : 

Benefit  societies,  93,  105 

Birth  rate,  186 

Births  attended  by  mid- 
wives,  197 

Boarders,  81,  231 

Death  rates,  44-48,  50-51, 
54 

Drugstore,  131-133 

Health  centers,  387 

Newspaper 

Magyar  Munkaslap,  167 

Physicians,  137 

Quacks,  150 

**The  Hungarians  of  Cleve- 
land," 296 
Hungary : 

Infant  mortality,  185 
Huntington,  J.  L.,  210 


Idaho : 

Midwifery,  205 
Illinois : 

Medical  service,  370 

Midwifery,  206 

Quacks,  167-168 
Illinois  Health  Insurance 
Commission : 

Benefit  societies,  94,  103, 
106-107 


Sickness  of  wage  earners, 
28-30 
Immigrant  customs: 
Diets,  246-279 
Maternity,  191-193 
Immigrant    heritages,    112- 
128 
Attitude,     121,     306-311, 

328-330 
Importance  in  health  work, 
294-299 
Immigrant   newspapers    {see 

separate  races) 
Immigrant  organizations: 

Benefit  societies,  92-111 
Immigrant  problems: 
Income,  394-396 
The  quack,  145-183 
Immigration : 

"Old"    versus    "new,"    6, 
184-185 
Indiana : 

Midwifery,  206 
Industry: 

Health  insurance,  401-404 
Health  work,  344-375 
Workers,  124,  344 
Homes  for,  78 
Infant  mortality: 
Bad  housing,  83-84 
By  nationality,  42,  58-63 
In  European  countries,  185 
Midwifery,  211-216 
Infections : 

Death  rate,  51 
Insanity : 

Among  foreign   born,  39- 
40 
International  Harvester 
Companies : 


472 


INDEX 


Employees*  Benefit  Asso- 
ciation, 357 
Interpreters : 

In  health  work,  241,  286- 
289,  313-318 
Irish: 

Alcohohsm,  56 

Births  attended   by   mid- 
wives,  197 

Boarders,  81 


Mahiutrition,  37-38 
Maternity  care,  231 
Maternity    customs,   192- 

193 
Midwifery,  197-198,  211- 

212,  218 
Phrase  books,  291 
Physicians,  108,  135,  137 
Quacks,  150 
Sickness,  34-39 


Death    rates,    43-57,    61,   Italy; 


186 
Health  care,  333 
Health  center  for,  381 
Insanity,  39-40 
Mahiutrition,  38 
Mortality,  56-57 
Italian : 

Attitude,  307,    329,    331- 

333 
Benefit   societies,   93,  99- 

100,  105 
Bu-th  rate,  186,  439 


Food  habits,  253-255 
"Housing  m  Italy,"  90 
Infant  mortality,  185 
Midwifery,  199 


Jacobi,  Abraham,  214 
Japanese : 

Hospital  in  San  Francisco, 
322 

IMidwifery,  198 

Physicians,  322 


Births  attended  by  mid-   James,  Linda,  xxv 


wives,  197 
Boarders,  81 
Commission  for  health 

work,  301-302 
Death  rates,  35,  45-52,  61, 

186,  187 
Diets  for  sick,  256-257 
Food  habits,  253-255 
Health  care,  331,  333 
Health  center,  384 
Heritages,  113,  124 
Hernia,  352 
Hospital,  322 
Housing  conditions,  85 
In  agriculture,  420 
Insanity,  39-40 


Jenks  and  Lauck,  81,  344, 
353,  365 

Jewish: 

Attitude,  330,  331-332 
Benefit   societies,    93,   97, 

101,  105 
Bhth  rate,  439 
Boarders,  81 
Death  rates,  49 
Diets  for  sick,  261-264 
Food  habits,  257-261 
Health  care,  330-332,  381- 

384 
Heritages,  116-117,  122 
Hospitals,  321-323 
Insanity,  39-40 


473 


IMMIGRANT  HEALTH  AND  COMMUNITY 


Malnutrition,  37 
Maternity  care,  231 
Maternity   customs,   192- 

193 
Midwifery,  218,  220 
Physicians,  109,  135,  137 
Quacks,  150 
Sickness,  35-36 
Johnstown,  Pennsylvania: 
Infant  mortality  study,  62- 
63,  83-84,  189,  198 
Joint  Board  of  Sanitary  Con- 
trol, New  York  City, 
358 
Journal  of  Industrial  Hygiene » 
350 

K 

Kentucky: 

Midwifery,  205 
Knoeppel,  Charles  E.,  347 
Krasnow,  H.  R.,  146, 168 


Labor  camps,  365-368 
Labor     Sanitation     Confer- 
ence, New  York  City, 
359 
Labor  Unions : 

Health  work,  358 
Language : 

Factor,    in    health    work, 
126-127,  286-294,  336 
Legislation: 
Health 
Federal 
Fraud  Order  law,  171- 
172 


Pure  Food  law,  173- 
174 
State 
Control  of  quack,  175- 

176 
Industrial    health   in- 
surance, 401-404 
Midwife,  205-210 
Leiserson,  William  M.,  365 
Lettish: 

Attitude,  308 
Levy,  Julius,  207,  212 
Lewinski-Corwin,  E.  H.,  141, 

230-231,  332 
Lithuanian : 

Attitude,  308-309 
Benefit  societies,  94,  105 
Boarders,  81,  364 
Health  care,  331 
Heritages,  113 
Jewish  diets,  260 
Physicians,  135 
Quacks,  150 
Los  Angeles,  California: 

Midwifery,  206 
Louisiana: 

Health  work,  289 
Midwifery,  206 
Lovell,  Bertha  G.,  339 
Loyal  Order  of  Moose: 
Benefit  societies,  93 

M 

McNutt,  J.  S.,  84 
Magyar  {see  Hungarian) 
Maine: 

Health  work,  289 

Midwifery,  205 
Malnutrition : 

Children,  37-38 


474' 


INDEX 


Hamp 


Diets  for 

Armenian,  268 
Greek,  268 
Italian,  257 
Jewish,  261 
Polish,  272-273 
Slavic,  272-273 
SjTian,  268 
Turkish,  268 
Manchester,    New 
shire: 
Health  work,  290,  300 
Infant    mortality, 
84. 
Manny,  Frank  A.,  37 
Maryland : 

Midwifery,  206 
Massachusetts : 
Health  work,  289 
Licensing  dispensaries,  176- 

177 
Midwifery,  205 
Massachusetts  Bureau  of  Im- 
migration : 
Medical  frauds,  179 
Maternity  Care: 
Agencies,     187-190 

245 
Customs,  191-194 
Proposed  plan,  233-245 
Training 
Nurses,  238 


Maynard,  Massachusetts : 

Foreign-born  physician,  136 
Memphis,  Tennessee: 

Midwifery,  207 
Menus : 

Immigrant,  277-278,  311- 
313 
Metropolitan  Life  Insurance 

Company,  27 
Mexicans : 
Texas,  299 
In  labor  camps,  367 
62-63,   Michigan: 

Industrial  health  work,  345, 

368-370 
Midwifery,  205 
Midwife  (The),  196-217 
Births  attended,  196-197 
Distribution  by  national- 
ity, 212 
European,  199-200 
Legislation,  205-210 
Substitutes,  218-243 
Testimony   of   physicians, 

211-214 
Work,  196-200,  210-217 
218-   Minneapolis,  Minnesota: 
Quack  advertising,  167 
Minnesota : 

Industrial     health     work, 

345,  368-370 
Midwifery,  206 


Physicians, 225-226, 230-   Mississippi : 


231 

Maternity    Center    Associa- 
tion of  New  York: 
Work,  223-225,  238 
Midwifery  study,  219 
Maverick  Dispensary,  196 
May,  Charles  C,  362-363 


Midwifery,  205 
Missouri : 

Midwifery,  2-6 
Mock,  Harry  E.,  xxvi,  350 
Morbidity  {see  Sickness) 
Morgan  Park,  Mumesota: 

Housing,  364 
475 


IMMIGRANT  HEALTH  AND  COMMUNITY 


Mortality: 

Foreign  born,  56-58 
Need  for  data,  63-69 

Mother  Tongue : 

Classification,  6,  66-67 

N 

National     Organization     for 
Public  Health  Nursing, 
xxvi,  291,' 433-437 
National  Safety  Council: 

Accident  prevention,  353 
National  Tuberculosis  Asso- 
ciation, 296,  435 
Nebraska: 

Midwifery,  205 
Negro 

Health  care,  333 
Neighborhood : 

Dispensaries,  342-343 
Factor  in  health  work,  300- 

302 
Maternity  centers,  225 
Medical  resources,  130 
Nephritis: 
Diets  for 

Armenian,  269 
Greek,  269 
Italian,  256 
Jewish,  262 
Polish,  274 
Slavic,  274 
Syrian,  269 
Turkish,  269 
Netherlands: 

Infant  mortality,  185 
New  Hampshire: 
Midwifery,  205 
New  Haven,  Connecticut: 
Health  work,  289 


New  Jersey : 

Midwifery,  206-207 
New  Mexico: 

Midwifery,  205 
New  York: 
Births  attended  by  mid- 
wives,  197 
Health  work,  289 
Insanity  among  the  foreign 

born,  39-40 
Licensing  dispensaries,  176- 

177 
Maternity  care,  218 
Midwifery,  206 
Quack  advertising,  167 
New  York  City: 

Association  for  Improving 
the  Condition  of  the 
Poor,  188,  198,  202 
Dispensaries,  330 
Examination    of    drafted 

men,  33 
Health  care,  332 
Health  centers,  380-384 
Hospitals 

Bellevue,  204-205 
Italian,  322 
Jewish,  322 
Joint   Board   of   Sanitary 

Control,  358 
Labor  Sanitation  Confer- 
ence, 359 
Malnutrition  of  school  chil- 
dren, 37,  38 
Midwifery,  202 
Mortality 

By  nationality,  45-46 
Of  children,  61 
Physicians,  38-39 
Quacks.  149 


476 


INDEX 


Sickness  among  Jews,  Ital-  Nightingale,  Florence : 

ians,  34-36  Contribution    to    nursing. 

Study  of  childbirth,  189  237 

New  York  City  Department  Norfolk,  Virginia: 

of  Health:  Midwifery,  206 

Health  experiment,  3803-84  North    Adams,    Massachu- 


Industrial  health,  359 
Medical  fraud,  179-180 
Mortality,  50 
New  York  Milk  Committee, 

381 
New  York  State  Bureau  of 
Industries  and  Immi- 
gration : 
Quacks,  153, 160-162, 180- 
181 
New  York  State  Department 
of  Health: 
Births   attended  by   mid- 
wives,  197 
Foreign  -  language     litera- 
ture, 289 
Infant  mortality,  59-60 
Study  of  birth  rates,185-186 
New    York    State    Hospital 
Commission : 
Insanity     among     foreign 
born,  39-40 
New  York  State  Reconstruc- 
tion Commission: 
Tenement  House  Survey 
79-80,  88-89 
Newark    Department    of 
Health: 
Infant  death  rate,  214 
Midwifery,    196,  213-214, 
243 
Newark,  New  Jersey: 
Health  work,  378 
Midwifery,  207-210 


setts : 

Health  work,  377 
North  Dakota: 

Midwifery,  205 
Norton    Company,    Worces- 
ter, Massachusetts: 

Health  work,  360 
Norway: 

Infant  mortality,  185 

Midwifery,  200 
Norwegian : 

Newspaper 
Tidende,  167 

Quacks,  150 
Nurses: 

Community  work,  412 

Foreign  born,  284-286 

Foreign-language  speaking, 
290 

In  health  work,  379 

In  industry,  361 

Maternity,  223-240 

Service  to  foreign  born,  433 

Textbooks,  276-277,  291- 
292 

Trammg,  238 

o 

Occupation: 
Change  in,  124 
Of  foreign  born,  344 

Ohio: 
Licensing  dispensaries,176-. 
177 


477 


IMMIGRANT  HEALTH  AND  COMMUNITY 


Medical  service,  370 
Midwifery,  204,  206 
Ohio  Health  Insurance  and 
Old  Age  Pension  Com- 
mission : 
Benefit    Societies,    28-29, 

97-98 
Nationality  of  Physicians, 
136 
Oklahoma: 

Midwifery,  205 
Omaha,  Nebraska: 
Midwifery,  206 
Quack  advertising,  167 
Oregon: 

Midwifery,  205 
Organizations,    Immigrant 

{see  Immigrant) 
Out-patient  Work: 
In  hospitals,  326 
In  maternity  care,  219, 225 


Paine,  Alonzo  K.,  226,  233- 

241 
Pennsylvania: 

Health  work,  289 

Industrial  health  work,  345 

Medical  service,  370 

Midwifery,  198 

Sickness  of  wage  earners, 
28 
Pennsylvania  Health  Insur- 
ance Commission: 

Benefit  societies,  95 
Pennsylvania  Railroad : 

Accident  prevention,  356 
Perkins,  Frances,  238-241 
Philadelphia: 

Benefit  societies,  100 


Dispensaries,  330 
Health  work,  295 
Midwifery,  213 
Physicians: 

Foreign,  134-137,  339 
Industrial,    345-349,  369- 

370 
Japanese,  322 
Maternity  care,  196,  211- 

214,     219-223,     233- 

235,  239-240 
Points  of  view,  307 
Ratio  to  population,  121 
Training    for    maternity 

care,     225-226,    230- 

231 
Use  by  foreign  born,  136- 

142 
Work  in  benefit  societies, 

108-109 
Pittsburgh: 

Quacks,  149,  156 
Pneumonia  {see  Respiratory 

diseases) 
Poland : 

Jewish  diets,  259 
Polish: 

Attitudes,  307,  329,  351 
Benefit  societies,  94, 97-99, 

105 
Birth  rate,  186,  439 
Births  attended  by  mid- 
wives,  197 
Boarders,  81,  364 
Childbirth  study,  189-190 
Death  rates,  44,  48-51,  61, 

186 
Diets  for  sick,  272-274 
Food    habits,    252,    270- 

272 


478 


INDEX 


Health  care,  331,  333 
Health  center  for,  385 
Heritages,  113,  115,  121- 

123 
Hospitals,  322 
In  agriculture,  420 
Maternity  customs,  191 
Midwifery,  212 
Phrase  books,  292-293 
Physicians,  135-138 
Quacks,  150,  154-155,  397 
**The  Poles  of  Cleveland," 
296 
Polish  National  Alliance,  94 
Population: 

Age  distribution,  42 
Classification    for    foreign 

born,  66-67 
Increase  by  mother  tongue, 

6 
Ratio 
Of  medical  schools,  232 
Of  physicians,  121,  135- 
136 
Portugal : 

Jewish  diets,  259 
Portuguese : 

Benefit  societies,  93,  102- 

103 
Physicians,  109 
Quacks,  150 
Post  Office  Department : 
Control  of  medical  quack, 
171-172 
Prague,  Oklahoma: 

Quack  advertising,  168 
Price,  George  M.,  358 
Providence,  Rhode  Island : 
Foreign-born  physicians, 
136 


Health  work,  288 
Midwifery,  212,  218 

Q 

Quack: 
Among   immigrants,   145- 
183,  397 

R 

Ranson,  John  E.,  331 
Ravage,  Marcus  E.,  70,  72, 

116-117 
Recipes,  immigrant,  449-463 
Respiratory  disease: 

By  nationality,  35-36,  40- 
41 

Death  rate,  51-52 
Rhode  Island: 

Midwifery,  205 
Rickets: 

Among  Italian  children,  37- 
38,40 
Roberts,  Peter,  185,  351 
Roosevelt,  Theodore,  x 
Rumania: 

Jewish  diets,  260 
Rumanian : 

Boarders,  82,  364 

Health  centers,  387 
Rushmore,    Stephen,    226, 

233-241 
Russia : 

Food  habits,  252 

Infant  mortality,  185 

Jewish  diets,  259-260 
Russian: 

Attitudes,  307 

Benefit  societies,  105 

Birth  rate,  186 


479 


IMMIGRANT  HEALTH  AND  COMMUNITY 


Births  attended   by  mid- 
wives,  197 
Death  rates,  44-45,  186 
Diets  for  sick,  273 
Heritages,  113 
Malnutrition,  38 
Midwifery,  212 
Mortality,  57-58 
Newspaper 

Amerikansky  Russhy  Vi- 
estnik,  168 
Physicians,  137 
Quacks,  146,  150 
Ruthenian : ' 
Boarders,  81 


St.  Louis,  Missouri: 

Commonwealth  Steel  Com- 
pany, 354 
Dispensaries,  331 
Health  work,  295 
San  Francisco,  California: 
Dispensaries,  331 
Japanese  hospital,  322 
Quacks,  149,  153 
Sartorio,  E.  C,  114 
Scandinavian : 

Benefit  societies,  105 
Death  rates,  44, 48, 51, 186 
In  agriculture,  420 
School,  Medical,  225-230 
School,  Public: 
Elementary 

Health  work,  423-424 
Scotch: 

Births  attended   by   mid- 
wives,  197 
Death  rates,  44,  47-49,  51, 
54,  186 

480 


Selby,  C.  D.,  349 
Semet-Solvay    Company    of 
Detroit : 
Accidents    among     immi- 
grants, 353 
Serbians : 

Benefit  societies,  105 
Boarders,  82,  364 
Serbo-Croatian : 
Infant    Mortality    Study, 
189,  190 
Schapiro,  Mary  L.,  258-264, 

451-457 
Shenandoah,     Pennsylvania, 

294 
Sickness : 
Amount,  31-32,  35-36 
Cures  by  quacks,  148-149 
Duration,  28-30 
Economic  loss,  27-28 
Need  for  data,  63-69 
Slavic : 

Benefit  societies,  93 
Diets  for  sick,  272-274 
Food  habits,  270-272 
Health  care,  333 
Health  centers,  384 
In  agriculture,  420 
Insanity,  39-40 
Maternity  care,  231 
Midwifery,  199 
Newspaper 

Amerikansky  Russky  Vi- 
estniky  168 
Slovak : 

Benefit  societies,  105 
Boarders,  81 
Heritages,  113,  116,  122 
"New  Times"  Publishing 
Company,  167 


INDEX 


Quacks,  150 

*'The    Slovaks    of    Cleve- 
land," 296 
Slovenian : 

Benefit  societies,  95,  105 
Soble,  Jacob,  198 
Social  Service: 

Dispensary,  338-339 

Hospital,  318-321 
Social  Unit,  387-390, 408,415 
South  Carolina : 

Midwifery,  205 
South  Dakota: 

Midwifery,  205 
Spain : 

Jewish  diets,  259 
Spanish : 

Phrase  book,  291 
Springfield,  Massachusetts: 

Health  work,  288,  377 
Stebbins,  Elwyn,  201 
Stella,  Antonio,  38,  52,  55 
Sullivan,  Louis  R.,  33 
Sweden : 

Midwifery,  200 
Swedish: 

Anaemia,  352 

Malnutrition,  38 

Quacks,  150 
Switzerland : 

Infant  mortality,  186 
Syrian : 

Diets  for  sick,  269-270 

Food  habits,  264-268 

Health  centers,  381 

Heritages,  122 


phrase 


Texas: 

Baby  clinic,  299 
Midwifery,  205 
Thomas,  and  Znaniecki,  115 
Topeka,  Kansas: 
Foreign  -  language 
books,  291 
Tuberculosis : 

Death  rate,  53-55 
Diets  for 

Armenian,  269-270 
Greek,  269-270 
Italian,  256-257 
Jewish,  263 
Polish,  274 
Slavic,  274 
Syrian,  269-270 
Turkish,  269-270 
Preventive  work  with  Ital- 
ians, 301-302 
Tufts  Medical  School,  230 
Turkish: 

Diets  for  sick,  269-270 
Food  habits,  264-268 


U 


Tennessee: 

Midwifery,  205 


Ukrainian: 

Attitudes,  329-330 
United  States  Census,  6,  42, 
43,  44,  48,  51,  54,  59, 
105,  186,  187,  431 
United   States   Chamber   of 
Commerce : 
Accident  prevention,  354- 

356 
Industrial  housing,  366 
United  States  Commission  on 
Industrial  Relations: 
Sickness  of  wage  earners, 

28 
481 


^^i 


IMMIGRANT  HEALTH  AND  COMMUNITY 

United  States  Department  of  Waller,  H.  T.,  363 

Labor:  War: 

"Human  relations  in   in-  Effect,  8 

dustry,"  375  Watson,  Elizabeth  C,  xxvi 

United   States   Immigration  Welsh: 

Commission:  Births  attended   by  mid- 
Boarders     in     immigrant  wives,  197 

households,  81-82  Death   rates,   44,  48,  51, 

Co-operation   with   hospi-  54 

tals,  197  Western  Reserve  University, 

Fecundity    of    Immigrant  384 

Women,  184-185  West  Virginia : 

Immigrants  in  industries.  Midwifery,  205 

344-353  Whitensville,  Massachusetts: 

United  States  Public  Health  Industrial  village,  78 

Service,  xxvi,  368,  435  Wiley,  Harvey,  163 

University  Hospital  of  San  Williams,  J.  Whitridge,  214- 

Francisco,  322  215 

Utah:  Williams,  Talcott,  x 

Midwifery,  206  Williams,  Whiting,  375 

Wisconsin : 

V  Floating  labor  camps,  365- 

Van  Blarcom,  Carolyn,  200,  367 

205  Midwifery,  204,  206 
Veiller,  Lawrence,  301  Park  Falls  Lumber  Corn- 
Vermont:  pany,  366-367 

Midwifery,  205  Women: 

Virginia:  Immigrant 

Midwifery,  205  Benefit     societies,     96- 

Visiting  Housekeeper,  240  100 

Visiting  Nurses'  Association:  Death  rates,  186-187 

Cleveland,  Ohio,  291  Fecundity,  184-187 

Topeka,  Kansas,  291  Organizations,  276 

VoU,  John  A.,  X  Program 

Physicians,  223 

W  Woods,  Bertha  M.,  xxvi 

Wald,  Lillian,  294  Worcester,  Massachusetts: 

Waller,  Edith:  Health  work,  287 

English  -  Italian    phrase  Wyoming: 

book,  291  Midwifery,  206 

•       THE   END 


DATE  DUE 


iVWJ 


2003 


FEBTP333^ 


'M'lr 


W 


J  4 


3W 


I*?Ofl* 


gyit^ 


004 


tMJ^    ..■ 


iiyifc 


DEMCO  38-296 


COLUMBIA  UNIVERSITY 


0027093891 


